A case of acute urinary retention after cesarean section caused by herpes zoster infection

doi:10.4236/ojog.2012.23040

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Open Journal of Obstetrics and Gynecology, 2012, 2, 202-205 OJOG

http://dx.doi.org/10.4236/ojog.2012.23040 Published Online September 2012 (http://www.SciRP.org/journal/ojog/)

A case of acute urinary retention after cesarean section

caused by herpes zoster infection*

Atsushi Yoshida#, Kenji Ishii, Keiko Saito, Isao Azuma

Department of Obstetrics and Gynecology, Nishisaitama-Chuo National Hospital, Tokorozawa, Japan

Email: #[email protected]

Received 12 May 2012; revised 15 June 2012; accepted 30 June 2012

ABSTRACT

We experienced a case of acute urinary retention

after an elective cesarean section. In this case, an epi-

dural catheter was inserted for the postoperative pain

relief, and we had to rule out anesthetic complications

including epidural hematoma. After careful investi-

gation, sacral herpes zoster was found to be respon-

sible for urinary retention. Early administration of

antiviral agent was started and the outcome was good.

As various factors may lead to postpartum urinary

disorders, we should be careful not to miss serious

complications.

Keywords: Anesthesia; Cesarean Section; Herpes Zoster;

Postpartum; Urinary Retention

1. INTRODUCTION

Postpartum urinary disturbance is a relatively common

complication, which may be caused by a variety of fac-

tors. Urinary retention after cesarean section can be

caused by surgical or anesthetic procedures and prompt

response is necessary because delay in the diagnosis and

therapy may result in severe aftereffects. Herpes zoster is

one of the diseases which may cause acute urinary reten-

tion, and the clinical course is strongly affected by the

timely initiation of the therapy. We here present a case of

acute urinary retention as a chief complaint after cesar-

ean section caused by herpes zoster infection.

2. CASE REPORT

The patient was a 40-year-old Japanese woman, para

1-0-2-2. Her height was 154 cm and pregestatinoal

weight was 41 kg (body mass index was 17.3). Her past

history was remarkable in that she had a cesarean section

in her previous twin pregnancy. The patient also stated

that she had had 2 spontaneous abortions in the first tri-

mester.

Repeat cesarean section was scheduled at 38 weeks

and 4 days. Preoperative laboratory data showed no par-

ticular problems (Tabl e 1). Cesarean section was carried

out as scheduled. Spinal anesthesia was administered

successfully at the L 3 - 4 interspace using 0.5% hyper-

baric bupivacaine 1.8 mL plus fentanyl 10 μg. Prior to

the spinal anesthesia, an epidural catheter was inserted at

the L 1 - 2 interspace for the postoperative pain relief.

Total blood loss including amniotic fluid was 856 ml and

cesarean section was successfully performed uneventfully.

A transverse skin incision was made on the old Pfannen-

stiel scar. A transverse incision was made into the ante-

rior wall of the lower uterine segment. The patient was

delivered of a 2886 gram boy infant in good condition.

After the surgery, 0.2% ropivacaine hydrochloride was

continuously given from the epidural catheter. On the

second postoperative day, the epidural catheter was re-

moved and no remarkable abnormal findings were noted

by inspection or subjective symptoms. Heparin calcium

of 5000 units was subcutaneously given on the evening

of the surgery, on the morning of first postoperative day

Table 1. Preoperative laboratory data.

WBC (×103) 6.9PT(sec) 9.6 TP (g/dl)5.8

RBC (×104)398APTT(sec) 27.1 Alb (g/dl)3.5

Hb(g/dl)12.0 GOT (IU/l)12

Ht (%) 36.3 GPT (IU/l)9

Plt (×104)19.3 LDH (IU/l)155

CPK (IU/l)33

BUN (mg/dl)6.3

Creat (mg/dl)0.5

Na (mmol/l)138

K (mmol/l)4.1

Cl (mmol/l)104

*Disclosure: None of the authors have any conflicts of interest associ-

ated with this study.

#Corresponding author.

OPEN ACCESS

A. Yoshida et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 202-205 203

and the evening, and on morning of the second posto-

perative day.

Her postoperative course was uneventful until the 6th

postoperative day. The patient complained of difficulty in

urination and hypesthesia on her right lower abdomen

and the medial surface of her right thigh. On the 7th

postoperative day, the urethral catheterization was nec-

essary because of urinary retention. The urethral cathe-

terization was carried out 5 times on the 7th postopera-

tive day and the total volume of catheterized urination

was 2300 mL. We suspected that the urinary retention

might be caused by an epidural hematoma as a complica-

tion of the epidural catheterization. Magnetic resonance

imaging of the spine revealed no abnormal mass which

might be compressing the spinal cord (Figure 1). We

consulted the anesthesiologists and they did not think the

urinary retention as a complication of anesthetic proce-

dures. On the 7th postoperative day we found hypochro-

mic erythema on the skin of the patient’s right sacral

distribution (Figure 2). On the 8th postoperative day, the

patient was examined by a dermatologist and she was

diagnosed as having herpes zoster. Serum antibodies of

varicella zoster virus was markedly elevated with IgG

index at 128 (positive ≥ 2) and IgM index 1.87 (posi-

tive ≥ 0.80) and we considered that urinary retention had

been caused by herpes zoster. The patient complained of

slight pain but later of the sacral lesion accompanied by

numerous vesicles, some of which broke down to form

ulcerations. Gentamicin sulfate ointment was applied

locally and aciclovir was given intravenously (250 mg ×

3 per day) for 7 days, followed by mecobalamin 500 μg

× 3 per day orally. Because the urinary retention contin-

Figure 1. Spinal MRI of this case. No abnormal mass such as

epidural hematoma was noted.

Figure 2. Hypochromic erythema on the skin of the patient’s

right sacral distribution.

ued, we consulted the urologists, who recommended in-

serting of an indwelling catheter. However, the patient

chose intermittent self catheterization was shown how to

do it.

On the 16th postoperative day, although the patient

could not void, she chose to be discharged from the hos-

pital and her self catheterization was continued. After the

discharge, urinary retention improved gradually and on

the 29th postoperative day the patient became able to

urinate. The sacral lesion improved and mecobalamin

oral administration was stopped. No recurrence of uri-

nary retention was noted.

3. DISCUSSION

Postpartum urinary disturbance is a relatively common

complication. After vaginal delivery, difficulty in urina-

tion or urinary retention often occurs as a result of cari-

ous factors such as fetal head compression on the pe-

ripheral nerve during labor, paralyzed urinary bladder,

urethral edema or abdominal muscle relaxation. These

urinary disturbances after vaginal delivery usually im-

prove shortly. Postoperative urinary disturbance after

cesarean section is also a relatively common occurrence,

which may be affected by various factors such as post-

partum bladder dysfunction and complications by surgi-

cal or anesthetic procedures [1-3]. It is reported that 1)

multiple pregnancy, 2) lack of progress in labor, 3) low

maternal body mass index and 4) use of postoperative

analgesia are the risk factors for postpartum urinary re-

tention after cesarean delivery [2,4,5]. Therefore, this

case was thought to be high risk for postpartum urinary

retention because it meets the factors (3) and (4) de-

scribed above. The incidence of postpartum urinary re-

tention associated with postoperative analgesia was re-

ported to be affected by the analgesics and administration

A. Yoshida et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 202-205

204

methods [4,6]. Epidural analgesia with morphine was

thought to increase post-cesarean urinary retention [6].

Not only cesarean section, but also post surgical epi-

dural analgesia is often complicated by urinary retention,

which usually disappears shortly after the discontinuance

of analgesics [7]. Therefore, it was thought to be unlikely

that urinary retention in this case was directly caused by

epidural analgesia. On the other hand, inserting or re-

moving epidural catheter may cause an epidural hema-

toma, which can lead to urinary retention. Epidural he-

matoma caused by epidural catheter is usually associated

with bleeding tendency in patients with complications

such as coagulopathy, liver disease or anticoagulant

medications. In our hospital, subcutaneous injection of

heparin is used for preventing postoperative venous

thrombosis in almost all cesarean cases but in the heparin

administered cases, the epidural catheter is removed at

least 4 hours after heparin injection. In this case of post-

operative heparin injection the epidural catheter was re-

moved after 5 hours of last heparin. Therefore, the possi-

bility of an epidural hematoma caused by removal of the

epidural catheter was not thought to be strong, but an

epidural hematoma formation in a patient ordinary with-

out bleeding tendency is reported [8]. Epidural hema-

toma is usually thought to be formed shortly after inser-

tion or removal of epidural catheter, but the formation of

epidural hematoma 9 days after removal of the epidural

catheter is reported [9]. In our case, urinary retention

occurring 6 days after the insertion and 4 days after the

removal of the epidural catheter could not readily rule

out the relationship between urinary retention and hema-

toma by the epidural catheter. Spinal MRI was obtained

immediately, but no epidural hematoma or other mass

which might be compressing the spinal nerves was noted.

Herpes zoster is an infection caused by varicella zoster

virus. The primary infection with varicella zoster virus

develops as varicella (chicken pox) and results in in-

flammatory lesion of the sensory root ganglions, menin-

ges or spinal cord. After the primary infection, the virus

enters the latent phase and remains dormant indefinitely.

The reactivation and proliferation of the virus may recur

as herpes zoster. It is reported that herpes zoster is

reactivated by various factors such as advanced age,

physical or psychological stress, general fatigue, trauma,

common cold or impaired immunity in patients on ste-

roids, malignant tumors or anticancer drugs [10]. In our

current case, the patient was suspected to be at high risk

for herpes zoster because she was in the postoperative

period with fatigue and physical and psychological

stresses. Usually herpes zoster is complicated by sever

pain along the innervations, although in this case the

patient complained little pain. Gluteal cutaneous lesion

in this case was considered to be innervation area of the

sacral nerve. Urinary retention is a common complica-

tion of zoster [11]. Sacral herpes zoster is thought to

induce detrusor areflexia by an inflammatory reaction,

which begins in the dorsal root ganglia and spreads to the

sacral segments of the spinal cord, and causes urinary

retention as the result, but it is reported that lumber or

thoracic zoster may cause urinary retention [12]. Sacral

herpes may also cause rectal disorders, but in this case

her rectal function was intact. In the therapy of zoster,

prompt use of antiviral agents is very important. It is

preferable to start antiviral agents within 72 hours of

cutaneous-lesion outbreak. In this case, accurate time of

onset of the erythema was unclear, but we could start

aciclovir within two days of urinary retention, which was

thought to be relatively early initiation of antiviral

therapy. In the drug package insert (in this case we used

VICCLOX I.V. Infusion 250 mg by Kobayashi Kako Co.

Ltd. Japan), concerning the use of aciclovir during the

lactation period, it is written that “nursing mothers should

discontinue breast feeding during treatment (transfer of

this drug into breast milk has been reported).” However,

Japan Drug Information Institute in Pregnancy (JDIP) in

National Center for Child Health and Development

announces that use of aciclovir is thought to be safe

during nursing period. In our case, we explained to the

patient the product document and the announcement by

JDIP. After obtaining the informed consent, nursing was

continued and no particular problems were noted.

4. ACKNOWLEDGEMENTS

I am deeply grateful to Dr. Mitsunao Kobayashi who provided helpful

comments and suggestions.

REFERENCES

[1] Kermans, G., Wyndaele, J.J., Thiery, M. and DeSy, W.

(1986) Puerperal urinary retention. Acta Urologica Bel-

gica, 54, 376-385.

[2] Evron, S., Samueloff, A., Simon, A., Drenger, B. and

Magora, F. (1985) Urinary function during epidural anal-

gesia with methadone and morphine in post-cesarean sec-

tion patients. Pain, 23, 135-144.

doi:10.1016/0304-3959(85)90055-7

[3] Dray, A. and Metsch, R. (1984) Inhibition of urinary

bladder contractions by a spinal action of morphine and

other opioids. Journal of Pharmacology and Experimen-

tal Therapeutics , 231, 254-260.

[4] Chai, A.T., Wong, T., Mak, H.L.J., Cheon, C., Yip, S.K.

and Wong, A.S.M. (2008) Prevalence and associated risk

factors of retention of urine after cesarean section. Inter-

national Urogynecology Journal, 19, 537-542.

doi:10.1007/s00192-007-0470-1

[5] Liang, C.C., Tseng, L.H., Horng, S.G., Lin, I.W. and

Chang, S.D. (2007) Correlation of pelvic organ prolapse

quantification system scores with obstetric parameters

and lower urinary tract symptoms in primiparae postpar-

A. Yoshida et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 202-205

205

OPEN ACCESS

tum. International Urogynecology Journal, 18, 537-541.

doi:10.1007/s00192-006-0195-6

[6] Liang, C.C., Chang, S.D., Wong, S.Y., Chang, Y.L. and

Cheng, P.J. (2010) Effects of postoperative analgesia on

postpartum urinary retention in women undergoing ce-

sarean delivery. Journal of Obstetrics and Gynecology

Research, 36, 991-995.

doi:10.1111/j.1447-0756.2010.01252.x

[7] Shadle, B., Barbaro, C., Waxman, K., Connor, S. and Von

Dollen, K. (2009) Predictors of postoperative urinary re-

tention. American Surgeon, 75, 922-924.

[8] Chung, J.H., Hwang, J., Cha, S.C., Jung, T. and Woo, S.C.

(2011) Epidural hematoma occurred by massive bleeding

intraoperatively in cesarean section after combined spinal

epidural anesthesia—A case report. Korean Journal of

Anesthesiology, 61, 336-340.

doi:10.4097/kjae.2011.61.4.336

[9] Guffey, P.J., Mckay, W.R. and Mckay, R.E. (2010) Epi-

dural hematoma nine days after removal of a labor epi-

dural catheter. Anesthesia & Analgesia, 111, 992-995.

[10] Eshleman, E., Shahzad, A. and Cohrs, R.J. (2011) Vari-

cella zoster virus latency. Future Virology, 6, 341-355.

doi:10.2217/fvl.10.90

[11] Yamanishi, T., Yasuda, K., Sakakibara, R., Hattori, T.,

Uchiyama, T., Minamide, M. and Ito, H. (1998) Urinary

retention due to herpes virus infections. Neurourology

and Urodynamics, 17, 613-619.

doi:10.1002/(SICI)1520-6777(1998)17:6<613::AID-NA

U5>3.0.CO;2-2

[12] Julia, J.J. and Cholhan, H.J. (2007) Herpes zoster-associ-

ated acute urinary retention: A case report. International

Urogynecology Journal, 18, 103-104.

doi:10.1007/s00192-006-0066-1