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$45 for three month plan equivalent to $15 per month required new customer offer for first three months only. Speed slow after 35 gigabytes of networks busy, taxes and fees extra. C mintmobile.com so I think we kind of laid this out already in the intro that per postpartum urinary retention is either two types. It's overt. In other words, symptomatic and covert. Asymptomatic. Maybe it's found on a CT scan or as a point of care with a bedside ultrasound as a scanner. The point is be aware that women who either had a vaginal or a C section and have this weird, just kind of persistent pain. Yes, it could be after pains. Yes, it could be a low pain tolerance. Yes, it could be cultural. But always, always listen to the patient, especially after surgery, because weird stuff happens. It could be a vessel that has spasmed and has now become a broad ligament hematoma or something else. So have a low index of suspicion here to get a diagnostic study. Again, a bedside ultrasound can do a lot and, or a CT scan. All the dyes are okay breastfeeding, so the value there is not to miss something. I think I had an episode in the past. I think I did it, or maybe not, but we actually did this as a scientific poster at one of our meetings where a patient had vaginal delivery, precipitous labor, no big deal. She was a multigravita. Vaginal birth, Right? No big deal. Well, I get called, this is like, I don't know, five years ago. I get called to go see her because she's like writhing in pain. Like, oh, my God, like, what is happening? I mean, in true, like 10 out of 10 pain. Right. So I'm like, what? Oh my gosh, something is awfully wrong here. What is going on? And so I can't even touch the vagina because she's so tender. So I'm like, well, I can't do a bimanual exam. She's not overtly bleeding. I, I, I don't know what is happening. So we, with permission, we gave her a little verse head, kind of relax her, sedate her, put her in a scanner well through her sacrum hollow. Right. So through the sacrum, right on top of the sacrum was this big, whopping, organized hematoma. Yep. As that baby's head descended naturally and quickly down the birth canal, it just kind of some pre sacral venous plexus. And she had an organized clot in the sacral hollow. Y', all. From a vaginal delivery. Always listen to patients. So what do we do for that? Well, we tracked her H and H, we followed her vital signs, made sure she was afebral. So it didn't get infected. No, we didn't go back and open that up because in the retroperitoneal space or in the pre sacral plexus, you're likely not going to find a direct bleeder. Just going to pressure itself off as it goes through the periosteum. But that's exactly what happened, guys. Now that's different than, like, if you're Doing a sacral copopexy and you hit a vessel intraop, you got to fix that. I mean, you punctured a vessel. But if it's a spontaneous bleed, it's actually going to collect right there in the sacrum hollow and it's going to seal itself off, which is exactly what happened. Very bizarre. Very bizarre. So short of it is it? Point is, listen to the patient and do a test to find this same thing for postpartum urinary retention. All right, If a patient has weird pain and you can't explain it, image, image of something. And if it's negative, fantastic. And this patient in our service this week, she was afebrile, she was non tachycardic. So the index of suspicion that she was bleeding wasn't necessarily there. But I got this to make sure that she didn't have an organized hematoma that was no longer active but was giving her persistent pain. Lo and behold, we found the distended bladder. Okay, now the definition, as we mentioned, of urinary retention kind of varies based on you read, but in general, some use either a four or a six hour inability to void after either spontaneous vaginal delivery or after catheter removal from C section. Okay, so whether you have a vaginal delivery or C section anywhere from a four or six hour interval, most women would avoid it. So look at your institution, see, do you use a four hour or a six hour? My preference is a four hour. That's what we do here because six hours you can get behind the ball and then further aggravate urinary retention. So four hours after catheter removal or four hours postpartum, just as an idea to see if there's some ability to void. All right, now if they haven't voided, rather than just putting an in and out catheter, which is fine to do always, less invasive is better. So doing a bladder scan, if your postpartum unit has that, we've got several, is a great way to assess and to estimate volume. And based on bladder scan, they're actually very good and are pretty darn accurate in terms of the estimated volume as opposed to in and out catheterization. Okay, but the question that we're following here is does bethanicol help? Should we be doing that or is there another avenue? And we are going to touch on the peppermint oil thing in just a minute because there was a recent study, guys, just in May of 2024 out of Aowon. All right, in their journal that this is very interesting again, Peppermint oil has been around for a long, long time. But before we get into that, very quickly on the pathophysiology of why this happens, and the short answer is you got to pick a reason, because there's a variety of reasons and all of them contribute to various degrees. I'm talking about in the postpartum patient, right? Not because you put a sling too tight or she's got horrible diabetes for 30 years and now she has a neuropathy, which is a neurogenic bladder. It's not what we're talking about. We're talking about in the otherwise healthy postpartum patient with her vaginal or section and then she just can't pee. There's several things going on there. First, of course, there are regular hormonal pregnancy related changes, including the progesterone effect, because progesterone absolutely affects detrusor function. You also have periurethral and vaginal inflammation that can put pressure at the mid urethra and the bladder neck, especially with a vaginal delivery, that can affect voiding. Then of course, you've got nerve palsy just from nerve stretching as the baby travels down the birth canal. And even with a C section, especially if you go with some extensions like in our case that were inferior, which were behind the bladder, as you put stitches, that surrounding inflammation can also affect bladder, neck or trigone function. Okay, so there's a variety of reasons why the bladder may not work, right? So to say it's just one thing. It's very hard to say because there's a lot of reasons in there. Now, there have been some studies that have looked at specific two main risk factors that increase the risk, the odds ratio of this happening, and that is a prolonged second stage where you have a lot of bladder descent with pushing and the second is some kind of operative vaginal delivery. Okay. Now the odds ratio of how much that actually increases the risk of retention varies based on who you read. But in general, those two things prolong second stage with bladder motility during second stage and or a operative vaginal delivery. That seems to be the big issue here that drives this occurrence. Believe it or not, even macrosomia has been looked at, and that's not really a thing. Anal sphincter injury has been looked at, and that's some part of a contributor, but not as much as having operative vaginal delivery as well as rotational descent of the bladder at second stage. There was a nice review that did this. It was a systematic review of these risk factors. It was back in 2012. So over 10 years ago in BJOG. And according to this systematic review, operative vaginal delivery seemed to carry the highest, the biggest risk association. Remember, not causation, but just risk association with per postpartum urinary retention. All right, so before we get into the meds of bethanicol and whether this works or not, I'm going to talk about what bethanicol actually is. Because bethanicol, everybody says, oh, yep, I get that. That's acetylcholine. Well, kind of. It's not really acetylcholine. I mean, it's an acetylcholine like agent, but it's not necessarily directly acetylcholine. So we're going to talk about that and of course we're going to talk about the management of postpartum urinary retention, which, number one is patience, because it's got to wait. It typically should resolve in the vast majority, almost 97, 98% of the time. This thing resolves within the first three days. We're also going to talk about indwelling catheter user or in now catheterizations, when that may be necessary. Okay, so we just wanted to kind of lay out the pathophysiology, lay out the reasons why. And now when we come back from this quick little break from our mid episode interlude, we're gonna get into medications and then we're gonna start to wrap this up. So we'll be right back. Hey, we're glad you're part of our podcast community. You're listening to Clinical Pearls. Eczema isn't always obvious, but it's real. And so is the relief from EBGLIS. After an initial dosing phase, about 4 in 10 people taking EBGLIS achieved its relief and clear or almost clear skin at 16 weeks. And most of those people maintain skin that's still more clear at one year with monthly dosing.

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All right, everyone, so let's get to it. Regarding medications, there are two medications that traditionally have been used for this. One is for the prostate. So that's obviously not FDA approved for postpartum women. But. But let's just get that out there because there are some data. Again, not good quality data, but there is data of using an alpha blockers like Flomax. That's Tamsuluin. That can work. So Tamsilocin definitely is an option for Flomax. By the way, every time I use the generic term for flomax, which is temsulosin, I say it differently. I don't know why. Tem. I hate that word, temsulosin. It just doesn't come out easy in my half Texan, half Latino accent. So Flomax. All right, so Flomax, remember, as an alpha blocker, yes. Something that you can try, but technically, well, not technically, it is off label because that's meant for the prostate. So nonetheless, there is a medication that's FDA approved for this actual diagnosis of acute postpartum non obstructive urinary retention. And that is bethanicol. Okay, now, Bethany call is if you've never heard of this, that's all right. It's been around since 1935. But if you haven't heard about it, that's all right. You may not have heard about it because it's not really used that much. Most people don't use this because it doesn't really do anything. Even if you have like urinary retention from surgery, like a very tight anterior repair or a sling, that's Too tight. That's an obstructive issue, man. You gotta let that inflammation go down. This is not gonna help with that. Methanicol is FDA approved for acute, non obstructive postpartum urinary retention. Now its actions are very similar to that of acetylcholine. But the reason I said it's not acetylcholine is because the way that it's metabolized in the body is actually not through cholinesterase. Okay, so that's why it's not directly an acetylcholine molecule, but it's acetylcholine. Like, nonetheless, it functions pretty similar to this. What it does is this coronary amine. The way that it hits that receptor is that it helps with detrusor contraction. Right? So if you have a very boggy uterus, this medication helps with detrusor function. Right? So that's only going to work, of course, if you have a non obstructive condition. Now there's different dosages that have been used anywhere from five or ten milligrams. You got to take it frequently, like up to three times a day. But, but the studies that have looked at this guys for over 30 years are very meh. It's like, you know what, it's not great. I mean, shoot, if you just wait enough like three days, maybe five at max is going to go away by itself and you don't get some of those weird side effects of bethanicol. In a randomized double blind placebo controlled trial, oral bethanicol was not shown to improve residual volume amount or the voided urine amount or even the mean flow rate. So this is something that's again been looked at with level one evidence and probably not a big, big win here. Side effects of bethanicol do include some flushing, some tachycardia. It can give patients diarrhea and oddly enough can give them urinary urgency, but not necessarily increased urine flow. So you just pretty much made them even more miserable because now they can't pee and they gotta poop real bad. So again, I'm not against it. If you want to use it, that's fine. But the data, the evidence for many, many years has shown that it has had lackluster efficacy compared to patients just waiting, just having patience and, or having bladder rest to let the bladder not work, let it regain its own function with some indwelling. Foley use anywhere from 12 hours up to 24, because the longer you have an indwelling potentially increases the risk of infection. So we don't want to do that either. Okay. Plus, if they're breastfeeding, even though it seems to be safe, it's very scant and very sketch data where their bethanicol is secreted into the breast milk. So as of right now, the fda, the lact medicine categorization is caution should be used when treating women who are breastfeeding or expressing milk for infant ingestion after taking bethanicol. End quote. So there you go. Now the exact same story times two can be stated for the alpha adrenergic receptor antagonist which we've just talked about, which is Flomax. All right, so rather than working on the bladder dome and the detrusor like methanecol, this actually works at the bladder neck to try to relax that, that. But if you have a relaxed bladder neck, but the bladder isn't contracting up on top, you can see why that's not really going to have a lot of effect here. So while there is data that this may help with some other conditions, even in the urogen population, there's really very scant to no good quality data that it helps resolve the issue of postpartum urinary retention. Okay. And the exact same story about its presence in breast milk, we just don't know. And as of right now, they are not routinely recommended for postpartum urinary retention or for breast feeding breast lactating patients. Boy, I couldn't get the word out there for lactating patients. Okay, so if you're like, well, crap, that medicine doesn't work, so then what do we do? Well, we've already said it. The mainly it's patience. Right? That's the good news is that postpartum really can be. Postpartum women can be reassured that this rarely lasts longer than 72 hours. And the clinical pearl here is to find it quickly because the longer there's a time to diagnose postpartum urinary retention, the longer the recovery can be because you've just stretched out the balloon of the bladder and it's going to have a very hard time bringing its tone back into place. It will, it's just going to take longer to do that. So outpatient options include either going home with a temporary indwelling or bladder self casts. Now, what I like to do is keep them another day in the hospital because it's worth it rather than sending home with a Foley that just kind of sucks. I'm like, hey, I know you want to go home. Why don't we just watch you overnight? We can pamper you, you know, you have somebody help you with the baby, you don't have to cook and get another night out of this. And then the morning we take the Foley out and then have you void vast majority of the time, not anecdotal, but publishing the data, that's going to do the trick. What's called persistent per, or long lasting postpartum urinary retention, is when it lasts beyond the first five days. The rate of that happening, and here's. Guys, here's the number that we tell our patients the chance of that happening is based on the data, not our own population. This is not the CHOPPA group. This is the literature at hand. The chance that this still persists after five days, assuming that there's nothing else going on, like there's a big hole in the bladder or somehow you stitch the urethra shut. Hey, whatever. I'm not throwing anybody under the bus, but I'm sure it's happened. And assuming that that's not the case, then the rate of persistent postpartum urinary retention after 120 hours is 0.05 to 0.18%. So there you go.05% to 0.18%. So yes, it does happen, but it happens at 0.05% up to 0.0.18%. Super, super small. Now that we've covered all that, a quick word about the peppermint oil. Yes, peppermint oil. Actually, I learned as I asked my nurses about this on our postpartum ward, they're like, hey, we've got peppermint oil actually in our nurse's cabinet for this very reason, because they heard me telling the patient, hey, if you get home and you feel that you can't avoid, don't put that directly on the skin. Because peppermint on the vajayjay may not be the wisest thing to do. Oh, can I deviate for a second? I'm gonna get in trouble for doing this. But nonetheless. So no names being given, but I remember this was, oh, I don't know, two, three years ago, where a student came to see me in my, in my university practice and said, you know, something is wrong. It's really burning down there. To which I go, oh my gosh, it's burning. Is this herpes? What's going on? And they tell me what happened. It's like, well, you know, I. My partner, my boyfriend gave me oral sex. And so right now my flags are going up. I'm like, oh my gosh, it's been like two days. Oral sex. Maybe he transmitted HSV and she's got a new lesion. This poor 18 year old who's terrified, right? So I'm like, well, tell me, so what happened? Well, he was looking to spice things up a little bit. This is her story. And so he. Guys, listen to this true story, all right? About why you probably don't want to put peppermint oil directly on your vajuju. And so to spice things up, this boyfriend. Meaning? Well, trying to give her a little extra, you know, zing, zing, zang, zang. He took some red hots and had some red hots. You know, you don't know what red hots are. Guys, if you're listening outside of the US or these little tiny little pill, like red candies that are like the breath of Satan, okay? I mean, they are hot and they're called red hots. So he had a bunch of these in his mouth and went to, well, lick her clitoris. And so that lasted a good like 30 seconds to a minute. And she was, it was like on fire. So all to say, she was still tingling like two days later. And so we looked. No, there was no herpetic lesions, There was no ulcerations. Like it probably it's just kind of in your dermal layer, even though she had washed it off. And like, it's going to get better. Just relax. And then of course, she came back two days later. She's like, well, it's totally gone. But no more red hots for oral sex, FYI, no joke. Is that crazy or what? Same reason why you probably don't want to put peppermint directly in the vagina. This is always diluted. And then the anecdotal literature has this more as a vapor. In other words, putting in a couple of drops in some water, warm water in a hat, and then having the patient sit over that for about 10 minutes. That is all. We're not doing this for like an hour. For about 10 minutes. And then having them in a relaxed state, not forcing the urine out, but in a relaxed state, try to avoid. Well, that is pretty similar to the latest publication that looked at this from May of 2024 in a one's journal, right? I'm glad they did this. Look, guys, it was. It's a randomized clinical trial. It was at a level three maternity center. Good for them for thinking outside the box. But two big issues here. Number one, the total number of participants was 69. 69. I hated to use that number after my red Hot oral sex story. But nonetheless, it is true. The number was 69. It was 38 in the treatment group and 31 in the control group. Guys, let me stop here for a minute. So you all don't understand the kind of heat that I take here from my production team because they're like, why do you have. Just read. Stick to the script. The red hot thing's not in there. The 69 comment. I know I'm gonna get some kind of beradement from my producer about. Why do you have to say things like that? Because. Why not? Because it's. Look, it's fun, it's humorous, it's being transparent. It's being human Anyway, that offends you. So. Sorry. Anyway, patients participated were 69, 38 in the treatment and 31 in the control group. So these were all patients diagnosed with postpartum urinary retention if they had inability to spontaneously void six hours after vaginal delivery or six hours after the catheter was removed for a C section. Right. So this included both camps, vaginal and cesarean. Now, patients were blinded to the treatment. However. What do you think is the big handicap here, guys? Okay, so patients can be blinded to treatment, but can you not smell peppermint oil? See, that's one of the limitations that are like, well, we didn't tell patients what it was. We had sham drops, and then we had regular peppermint drops. But, damn, you can smell peppermint. So that's one of the issues that it was, quote, unquote blinded. But, yeah, with that limitation built in. And what happened here is they took 2mls of the oil placed in the collection hat, patients sat over the toilet, exposing the perineum to the vapors for 10 minutes, and then they tried to void. Remember, they all had some inability to void already. Well, did it work? For sure, it totally worked, but it wasn't statistically significant. Now, it could be that the reason it wasn't statistically significant was because the sample size was way too small. All right, so let me give you the numbers directly from the results section. So again, that's why I said, look, it's reassuring. It doesn't hurt. It could possibly help, but based on the sample size, it wasn't statistically significant. The primary outcome was resolution of postpartum urinary retention using a Fisher's exact test. Okay, fine. A total of 19 patients voided spontaneously, including 12 in the peppermint group, that was 63%, and seven in the mineral group that's only 37%. So you get that. So the percentage in those who voided was much greater in the peppermint group. However, the issue was it wasn't. When you actually do the math looking for statistical significance, the p value value didn't hit their significance based on their small sample size. So that's one of the issues here. So as they state quote peppermint oil increased spontaneous voiding. However, findings were not statistically significant to support it in clinical use. Limitations include a low sample size, lack of participation from management. That's weird. And true steady blinding because of the oil scent. So further research with a larger sample size is warranted. End quote. What's my take on this? It can't hurt. It can possibly help. Above all that, hey, peppermint smells good. So if you want to try that, knowing that there's kind of sketch low quality data that is level one nonetheless, then knock yourself out. Podcast family is one of my commitments. Remember what I said I was going to try to do? I was going to try to do this in a much quicker fashion because somebody told me that I was rambling. So that's going to bring us to a wrap on pur. Postpartum Urinary retention. As always, Podcast family, we're thankful for you. We're glad you're part of our podcast community and we'll see you on another episode of Clinical Pearls. Now let's take it home. Podcast family, we really are thankful for you. You. We hope you enjoyed this episode. We'll see you next time on Clinical Pearls Jam.