Management of Postpartum Urinary Retention: A National Survey of Protocols

Objectives: Postpartum urinary retention (PUR) occurs after 1.5-18% of deliveries. Institutional PUR protocols decrease PUR rates and improve management of this condition. In 2023, Nutaitis et al proposed a standardized PUR management protocol. The objectives of this study are to (1) identify and characterize PUR protocols at hospitals affiliated with US Ob/Gyn residency programs, and (2) review and compare protocols to the proposed standard.

Methods: US Ob/Gyn residency programs were identified through FREIDA, and program directors and coordinators were contacted to request institutional PUR protocols. Institutional and residency characteristics were collected from publicly available data, and compared using Mann–Whitney U test and Chi Square, as appropriate, with p< 0.05 defined as significant, using STATA. Residency and urogynecology faculty numbers were reported as median (interquartile range). Key steps in the proposed standard protocol were identified and compared against the institutional protocols. The presence of these steps was tallied, and volume and time recommendations were recorded.

Results: 295 programs were contacted and 103 (34.9%) responded. Three institutions declined participation, and four reported but did not provide protocols and were excluded. 25 institutions (24.3%) had a protocol with 3 institutions having separate protocols for cesarean and vaginal delivery. 58 institutions (56.3%) had no protocol. 13 institutions (12.6%) had an electronic order set with recommendations but no true protocol and were classified as no protocol.

Institutions with protocols were significantly more likely to have a urogynecology fellowship (60.0% vs 30.9%, p=0.01) and had a higher median number of urogynecology faculty (5 (2-7) vs 3 (2-4), p=0.008). There was no significant difference between median number of residents (24 (16-32) vs 20 (16-28), p=0.28) or regionality (p=0.44).

Protocols were reviewed for inclusion of 10 key steps from the proposed protocol (Table 1). All protocols included a time limit for first spontaneous void postpartum. For overt PUR, 22 (79%) of protocols included bladder scan if patient failed to void within the time limit and 17 (61%) recommended catheterization if postvoid residual (PVR) was above threshold. For covert PUR, 16 (57%) included an initial void volume concerning for covert PUR. 14 (50%) recommended bladder scan for PVR if voided volume was below threshold.

Figure 1A-D summaries four key steps and time/volume recommendations compared to the proposed protocol (proposed protocol’s value highlighted in black). Overall, the most common value for each step across all protocols coincided with the proposed standard.

Conclusions: Most academic institutions in the US surveyed did not have a PUR protocol, and a wide range of times and volumes are used to guide decision making across protocols that exist. Our study demonstrates a need for both increased utilization of PUR protocols and protocol standardization.