{"paper_id":"5d14d16d-3cd1-4652-91d7-0138c0b663e5","body_text":"Can Retrovert Uterus Be a Cause of Recurrent \nTemporal Acute Urinary Retention During Pregnancy?\n1Department of Urology, Faculty of Medicine, Yuzuncu Yil University, 65100 Van, \nTurkey\nReceived: 26.01.2012, Accepted: 10.02.2012\nCorrespondence: Department of Urology, Faculty of Medicine,\nYuzuncu Yil University, 65100 Van, TURKEY .\nTel: 90 432 2150470/6249,   Fax: 904322167519\nE-mail: ilhan_gecit@hotmail.com\nİlhan Geçit, Erdal Benli, Mustafa Güneş, Necip Pirincci, Zehra Kurdoğlu, Hüseyin Eren\nEuropean Journal of General Medicine\nCase Report Eur J Gen Med 2013;10(1):53-55\nINTRODUCTION\nAcute urinary retention (AUR) is rarely seen during preg-\nnancy. Its mechanism of action has not been fully under-\nstood but it is an urgent condition. Many anatomic and \nphysiologic alterations including dilations of ureters, \nincrease in urinary bladder capacity and reduction in \nurinary bladder tonus develop in urinary system during \npregnancy. Enlarged uterus causes urinary bladder to \nstuck toward anterior and upward (1). Movement of el -\nevated uterus toward abdomen may be limited by causes \nlike retrovert uterus, previous pelvic infections and \nendometriosis-related adhesions, myomas, periurethral \nabscesses, urethral diverticulum, incarceration of pelvic \nuterus, ectopic pregnancy, vulvar edema. In this case, \nuterus stucked in pelvis may lead to difficulty of mictura-\ntion (urination or micturition) and sometimes urinary re-\ntention by pressuring bladder neck and urethra between \nsacrum and pubic bones (2,3). In this paper , a 35-year \nold woman who experienced acute urinary retention at \nthe end of the first trimester in her previous two preg -\nnancies and applied with acute urinary retention again \non the 14th week of gestation is presented. As recurrent \nABSTRACT\nUrinary retention developing in early period of pregnancy is a rare but urgent condition. A few literatures were encountered \non this issue. Retrovert uterus, endometriosis, pelvic inflammatory event-related adhesions, ectopic pregnancy and intramural \nmyomas are among predisposing factors. These factors cause stucking of uterus in pelvic cavity by hindering elevation of uterus in \nthe abdomen and acute urinary retention may develop as the result of pressure to urinary bladder floor and urethra The case who \ndeveloped the urinary retention in her three sequential pregnancies has been discussed in the light of the literature in this paper.\nKey words: Urinary retention, pregnancy, pelvic cavity \nRetrovert Uterus Gebelik Esnasında Tekrarlayan Akut İdrar Retansiyon Sebebi Olabilirmi\nÖZET\nGebeliğin erken döneminde gelişen idrar retansiyonu, nadir olarak izlenen ancak acil yaklaşım gerektiren bir durumdur. Bu konuda \naz sayıda literatüre rastlanmıştır. Predispozan sebepler arasında retrovert uterus, endometriozis, pelvik inflamatuar olaylara \nbağlı gelişen adezyonlar, ektopik gebelik ve intramural myomlar yer almaktadır. Bu faktörler; uterusun batın içerisinde yük -\nselmesini engelleyerek, uterusun pelvik kavitede hapsolmasına neden olmakta ve mesane tabanı ile üretraya bası sonucunda da \nakut idrar retansiyonu gelişebilmektedir. Bu makalede, birbirini takip eden her üç gebeliğinde de üriner retansiyon gelişen olgu \nliteratür eşliğinde tartışılmıştır. \nAnahtar kelimeler: İdrar retansiyonu, gebelik, pelvik kavite\n\nEur J Gen Med 2013;10(1):53-55\nRecurrent temporal acute urinary retention\nturation (micturition) may be hindered. Filling of bladder \nmay also be hindered as a result of stucking of bladder \nand irritation findings like polyuria and dysuria may de-\nvelop related to this. Stucking of retrovert uterus is not \npermanent and improves with normally elevation of uter-\nus after a while. Although retrovert uterus is detected \nin the ratio of 11% during pregnancy, urinary retention \ndevelops only in 1% of these cases. Benefit of urodynam-\nic evaluations has not been shown in the assessment of \nthese patients (5,6). Yang and Huang reported that fac-\ntors leading to retention caused it by affecting pressure \nrate providing micturation (micturition). Some measures \nlike fluid restriction and micturation (micturition)  before \ngoing to bed,  leaning forward in sitting position before \nbeginning micturation (micturition)  (Crede maneuver , \ngetting to prone position from supine position before get-\nting out of the bed and avoiding valsalva maneuver  as \npossible have been introduced in order to prevent AUR as \nit usually develops at night and early in the morning (7). \nLove and Howell recommended a careful pelvic examina-\ntion in order to determine retrovert uterus or anterior \nmyoma in pregnant women applying with urinary com -\nplaints and also recommended aforementioned measures \nto these patients (7). Acute urinary retention is one of \nthe urgent conditions in pregnancy. The first procedure to \nbe done after physical examination is emptying bladder \nwith catheterization due to risk of high bladder rupture \nor neuromuscular dysfunction. Sometimes reduction of \nincarceration without uterin maneuver may be sufficient. \nUnfortunately, none of these methods would eliminate \nthe underlying factor. Persistence of urinary retention \nmay lead to complications like irreversible uterin isch -\nemia, spontaneous or septic abortus, uterus rupture, \nbladder rupture, chronic neuromuscular dysfunction of \nbladder , rectal gangrene and even maternal death (8). \nSpring and Hymes reported that AUR developing in preg-\nnancy was related to asymmetrical enlargement of uterus \n(anterior wall enlarges faster than posterior wall), thus \ncervix could lead to urinary retention by compressing \nbladder neck and urethra externally (9).\nIn traditional treatment of pelvic incarceration cases, pre-\nserving vesicourethral angle and decompressing bladder \nis recommended via putting uterus in anterior position in-\nstrumentally (pessary) or non-instrumentally. These pro-\ncedures may be applied under spinal anesthesia or epi -\ndural anesthesia when needed. This instrument (pessary) \nmay be removed beginning from the second trimester. \nTreatment should be done immediately to prevent pos -\nurinary retention in the early weeks of gestation was not \nencountered when we reviewed English literature, this \ncase is discussed in the light of the literature.\nCASE \nA 35-year-old, gravida 3, parity 2 patient was admitted \nto emergency room with complaints of abdominal pain, \nsevere back pain and failure to micturate for 14 hours. \nOn her first examination performed by an urologist af -\nter bladder was found to be extremely distended, it was \nlearned that the patient had polyuria and dysuria for a \ncouple of days. On her obstetric history, she was learned \nto undergo two caesarean sections and developed acute \nurinary retention on the same weeks in her previous preg-\nnancies. On her physical examination, her vital findings \nwere normal however a suprapubic mass and pain were \ndetected on abdominal examination. On her obstetric \nultrasonography, single alive fetus whose crown-rump \nlength was consistent with 14 weeks, retrovert uterus \nand extremely enlarged bladder were observed. A total \nof 1300 cc urine was emptyed (emptied) from the bladder \nvia an urinary catheter. Infection was not present on her \nurinary examination. In the patient who also examined by \ngynecology and obstetric specialists, no other pathologies \nconcerning pelvic organs could be found except retrovert \nuterus. No neurologic pathologies were detected in the \npatient. Thus the patient was decided to be monitored \nwith insertion of an urethral catheter. The patient who \nwas seen to be able to micturate spontaneously after re-\nmoval of catheter 10 days later was decided to be fol -\nlowed up. Amount of residual urine was measured as 40 \ncc on following days and the patient who did not develop \nurinary retention on her follow up underwent caesarean \nsection on the 39th week.\nDISCUSSION\nAUR in pregnancy is a rare but an urgent condition irritat-\ning the patient. Very few cases have been reported about \nurinary retention developing in early period of pregnan-\ncy. Although pathogenesis of AUR has not been fully ex-\nplained, the most elaborated mechanism is stucking of \nuterus in pelvis as the result of incarcerated myomas, \nretrovert uterus limiting natural movement of uterus and \nadhesions due to various inflammatory causes. As the \nresult of this, cervix makes pressure on neck and base \nof bladder and pushes bladder toward anterior thus mic-\n54\n\nGeçit et al.\nEur J Gen Med 2013;10(1):53-55\n55\nsible severe complications. Although clean intermittent, \ncontinuous catheterization or suprapubic catheterization \nmay be used for decompression of bladder but supra -\npubic catheterization is not recommended much (2,8). \nDevoe presented a case of urinary retention developing \nin early pregnancy first and reported that he treated this \nby supporting uterus via placing a vaginal instrument (2).\nSacco et al. reported that they treated urinary reten -\ntion developing due to pelvic incarceration in a pregnant \nwoman via emptying bladder with urethral catheteriza-\ntion together with manual reduction and antibiotherapy \n(5). In our case, AUR developed on approximately the \n14th week in all three sequential pregnancies. The point \nmaking this case interesting is the history of urinary re-\ntention on similar weeks in previous two pregnancies. No \nother pathologies except retrovert uterus were detected \nin our patient. Bladder was emptied via an urinary cath-\neter and antibiotherapy was applied. Urinary retention \ndid not recur after urinary catheter had been removed \nafter 10 days and the patient was followed up in conjunc-\ntion with Department of Gynecology and Obstetrics until \nthe end of her pregnancy. The patient in whom urinary \nretention did not recur underwent caesarean delivery on \nthe 39th week of gestation as she had two caesarean sec-\ntions before. Urinary retention developing in a pregnant \nwoman is an urgent condition that may lead to severe \ncomplications. Immediate catheterization should be done \nafter detection of urinary obstruction. The patient should \nbe followed up in conjunction with a gynecology and ob-\nstetrics specialist until the end of the pregnancy, physi-\ncians should be aware of urinary retention and should be \ninformed about the fact that this condition may recur in \nher following pregnancies.\nREFERENCES\n1. Waltzer WC. The urinary tract in pregnancy. J Urol 1981; \n125:271-6\n2. Devoe RW. Acute Urinary retention in pregnancy. Calif \nMed 1956;85:112-3\n3. Yellamareddygari S, Ahluwalia A. Acute vulval oedema \nwithurinary retention in pregnancy. J Obstet Gynaecol \n2006; 26: 815-6\n4. Yohannes P , Schaefer J. Urinary retention during the sec-\nond trimester of pregnanacy rare cause. Urology 2002; \n59: 946 \n5. Sacco F , Rigon G, Castaldo F , Carbone A, Sacchini D, \nSacco R. Acute urinary obstruction in pregnancy. Minerve \nGinecol 1993; 45: 101-4\n6. Yang JM, Huang WC. Sonographic findings in acute urinary \nretention secondary to retroverted gravid uterus: patho-\nphysiology and preventive measures. Ultrasound Obstet \nGynecol 2004; 23: 490-5\n7. Love JN, Howell JM. Urinary retention resulting from in -\ncarceration of a retroverted, gravid uterus. J Emerg Med \n2000; 19: 351-4\n8. Chauleur C, Vulliez L, Seffert P . Acute urine retention in \nearly pregnancy resulting fibroid incarceration: proposi -\ntion for manegement. Fertil Steril 2008; 90:1198 e7-10       \n9. Spring M, Hymes JJ. Acute urinary retention as a com -\nplication of pregnancy: report of a case. J Am Med Assoc \n1952; 149: 1011-2","source_license":"CC0","license_restricted":false}