CHRONIC NON-OBSTRUCTIVE URINARY RETENTION AND PELVIC FLOOR MUSCLE DYSFUNCTION FOLLOWING SURGERY FOR ENDOMETRIOSIS: A CASE SERIES.

A. Gehrich, C. Iglesia, J. Aseff, J. Buller

Silver Spring, MD

OBJECTIVE: To describe 4 cases of neuropathic, non-obstructive urinary retention associated with pelvic floor muscle spasm following benign gynecologic surgery for endometriosis.

MATERIALS AND METHODS: Four cases of non-obstructive urinary retention following both open and laparoscopic surgery for endometriosis were evaluated. All were referrals to the urogynecology clinic at Washington Hospital Center for further evaluation. These patients underwent a complete history, physical exam and diagnostic work-up to include urodynamics and pelvic neurophysiologic testing.  Cases were analyzed with regards to age, type and extent of inciting surgery, neurological findings and post-operative recovery and treatment.

RESULTS: The patients, age 37-44 years, all underwent extensive adhesiolysis for varying stages of endometriosis. All developed acute urinary retention post-operatively requiring prolonged catheterization, and subsequent Valsalva voiding and the use of the Crede’s maneuver. In conjunction with post-operative non-obstructive urinary retention, all developed increasingly severe pelvic pain associated with spasm of the levator ani and/or urethra sphincter muscles.  Neurological physical exams were equivocal with the exception of one patient who showed obvious obturator neuropathy. MRI showed no evidence of upper motor neuron lesions. Urodynamic testing showed varying degrees of detrusor hypotonia.  Cystoscopy was normal in all cases. On neurodiagnostic testing, all had absence of bladder-anal reflexes, and prolongation of the pudendal nerve terminal motor latency was identified in 2 of the 4 patients.   Electromyography studies of the external urethral external and external anal sphincter showed evidence of reinnervation in 3 of the 4 patients.  No patient experienced a return of normal bladder function in spite of aggressive pharmacologic treatment or physical therapy. Two of the four patients achieved partial success with chronic sacral nerve root stimulation.

CONCLUSIONS: Excision of deep infiltrative endometriotic lesions with extensive adhesiolysis does increase the risk of post-operative bladder dysfunction.  The resultant non-obstructive urinary retention appears to be neuropathic in origin.  All patients appeared to have developed increasing pelvic floor muscle spasms and pain requiring aggressive management with narcotics and muscle relaxants.  We believe that this condition results from a pelvic floor muscle imbalance in which healthy muscle compensates for adjacent, neuropathic muscle leading to muscle fatigue and spasm in various aspects of the pelvic floor musculature.  Early diagnostic evaluation with aggressive physical therapy is critical to minimize this complication.

Key Words: non–obstructive urinary retention, post-operative complication, pelvic surgery, endometriosis, pelvic floor muscle spasm

Disclosure - Speakers Bureau: C. Iglesia, Indevus.