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Incidence and risk factors of postpartum urinary retention following cesarean section: a retrospective nationwide inpatient sample database study

BMC Women's Health volume 25, Article number: 180 (2025) Cite this article

Abstract

Aim

To investigate the risk factors associated with postpartum urinary retention after cesarean section (CS) and to determine the associated morbidity rate.

Methods

This study was a population-based retrospective case–control study analyzed using National Inpatient Sample (NIS) data from 2010 to 2019. The study classified women according to whether they developed postpartum urinary retention after delivery. Predictors of postpartum urinary retention occurring after CS were identified by multivariate logistic regression analysis, and the corresponding incidence rates were examined after adjusting for basic maternal demographic and clinical characteristics.

Results

A total of 2,397,168 CSs were extracted from the NIS database. The overall incidence of urinary retention after CS was 0.20%. Patients who experienced urinary retention after CS demonstrated longer length of stay (LOS), higher total costs, and more postoperative complications. The following variables have been identified as potential risk factors for urinary retention: age between 25 and 34 years (OR = 1.27; 95% CI = 1.17–1.38; P < 0.001), 35 years and older (OR = 1.35; 95% CI = 1.22–1.48; P < 0.001), Asian and Pacific Islander (OR = 1.85; 95% CI = 1.68–2.05; P < 0.001), one comorbidity (OR = 1.51; 95% CI = 1.28–1.79; P < 0.001), two comorbidities (OR = 1.51; 95% CI = 1.09–2.08; P = 0.013), three and more comorbidities (OR = 1.79; 95% CI = 1.06–3.04; P = 0.031), large hospitals (OR = 1.16; 95% CI = 1.07–1.26; P < 0.001), teaching hospitals (OR = 1.93; 95% CI = 1.79–2.07; P < 0.001), eastern hospitals (OR = 1.24; 95% CI = 1.14–1.35; P < 0.001), coagulation disorders (OR = 1.32; 95% CI = 1.08–1.61), fluid and electrolyte disorders (OR = 2.46; 95% CI = 1.94–3.11), other neurological disorders (OR = 1.51; 95% CI = 1.20–1.89), paralysis (OR = 3.24; 95% CI = 1.95–5.38), and weight loss (OR = 2.34;95% CI = 1.26–4.35). In addition, urinary retention was associated with postoperative complications related to bladder or ureteral injury (OR = 6.12; 95% CI = 2.46–15.23), blood transfusion (OR = 1.51; 95% CI = 1.31–1.76), acute renal failure (OR = 4.74; 95% CI = 3.46–6.48), respiratory failure (OR = 2.21; 95% CI = 1.23–3.98), endometritis (OR = 1.32; 95% CI = 1.02–1.71), hemorrhage/hematoma ( OR = 2.52; 95% CI = 1.38–4.62), uterine rupture (OR = 1.75; 95% CI = 1.21–2.54), hysterectomy (OR = 2.30; 95% CI = 1.66–3.18), peritonitis (OR = 2.86; 95% CI = 1.03–7.92), severe puerperal infections (OR = 3.31; 95% CI = 2.60- 4.22), chorioamnionitis (OR = 1.78; 95% CI = 1.59–2.00). Notably, the presence of cephalopelvic disproportion (OR = 1.37; 95% CI = 1.11–1.67), breech or other fetal position abnormalities (OR = 1.10; 95% CI = 1.00–1.20), placenta previa (OR = 1.39; 95% CI = 1.06–1.84), multiple gestation (OR = 1.39; 95% CI = 1.23–1.58), anatomy of the bladder (OR = 3.93; 95% CI = 1.42–10.90), bladder catheter placement (OR = 22.57; 95% CI = 20.24–25.17) and intravenous infusion (OR = 1.22; 95% CI = 1.09–1.36) was associated with a significantly increased risk of urinary retention, while low cervical CS (OR = 0.62; 95% CI = 0.50–0.76), previous CS (OR = 0.87; 95% CI = 0.82–0.93) and prolapsed cord (OR = 0.52; 95% CI = 0.31–0.86) conferred some protective effect against it.

Conclusion

In this study, we identified an overall prevalence of 0.20% for urinary retention after CS and several risk factors, including advanced maternal age, Asian and Pacific Islander background, comorbidities, and delivery in large or teaching hospitals, particularly in the Eastern region. Protective factors included hospitals in the southern region, urban hospitals, obesity, and hypertension. Urinary retention was associated with increased postoperative complications, longer LOS, and higher healthcare costs. Several confounders also significantly influenced the incidence of urinary retention. To mitigate these risks, healthcare professionals should prioritize antenatal screening, manage comorbidities, and closely monitor high-risk patients during the postpartum period to reduce adverse outcomes.

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Introduction

The role of cesarean section (CS) in obstetric practice has evolved over the past century. Today, CS is one of the most common procedures among women of childbearing age worldwide, with approximately one-third of women in the United States undergoing the procedure, and it is one of the leading causes of increased maternal mortality and morbidity in the United States. In rare cases, CS saves the life of either the mother or the foetus, or both [1]. However, a variety of perioperative complications are important contributors to the high rates of maternal mortality and morbidity after CS, including uterine rupture, hemorrhage (which may result in the need for hysterectomy or blood transfusion), injury to adjacent organs (e.g., bladder or bowel), and thromboembolic disease [1,2,3].

Postpartum urinary retention is a relatively common condition that may significantly affect women in the days following childbirth [4]. If left untreated, postpartum urinary retention may lead to repeated overdistension injuries, which may damage the parasympathetic nerve fibres within the detrusor muscle and bladder wall. In rare cases, postpartum urinary retention may even lead to bladder rupture, thus becoming a potentially life-threatening but entirely preventable complication. According to available studies [5, 6], failure to deliver, CS, perineal tear or episiotomy, and infusion of fluids in the delivery room are strongly associated with the development of postpartum urinary retention.

Identifying patients at risk of urinary retention during CS will not only help to improve the accuracy of intraoperative injury detection, but will also be effective in reducing patient morbidity. In addition, by identifying high-risk patients, preoperative counselling can be better guided so that patients can make a well-informed decision about whether to undergo a CS. However, to date, there has been a lack of studies discussing the incidence and risk factors of post-CS urinary retention based on a large-scale sample. Therefore, the objectives of this study are: (i) to analyze the overall and annual incidence rates of hospital urinary retention following CS over a decade; (ii) to clearly describe the adverse outcomes for patients hospitalized with urinary retention after CS; (iii) to identify the risk factors for urinary retention within the hospital after CS. The study utilizes a national database to analyze patient demographics, hospital characteristics, length of stay (LOS), total costs during hospitalization, in-hospital mortality, comorbidities, and perioperative complications.

Material and methods

Data source

The National Inpatient Sample (NIS) database, maintained by the Healthcare Cost and Utilisation Project and funded by the Agency for Healthcare Research and Quality (AHRQ), is the data base for this study. The NIS is the most comprehensive inpatient database covering all payers in the United States. The NIS database has extensive coverage across the United States and contains a stratified sample of approximately 20% of inpatients from more than 1000 hospitals, representing more than 7 million hospitalisations in the United States each year [7]. The database contains patient demographic information, hospital resource data, and clinical diagnostic data, and the surgical information is carefully classified according to the International Classification of Diseases Ninth Revision, Clinical Modification Codes (ICD-9-CM) and the International Classification of Diseases Tenth Revision, Clinical Modification Codes (ICD-10-CM). As this observational study used anonymised, publicly available data, it was considered ethical.

Data collection

We screened all pregnant women undergoing CS by using the International Classification of Diseases Ninth Revision (ICD-9) procedure codes 74.0, 74.1, 74.2, 74.4, 74.99 and the International Classification of Diseases Tenth Revision (ICD-10) procedure codes 10D00Z0, 10D00Z1, 10D00Z2, and excluded patients with missing data (Fig. 1). Subsequently, within this group, we used the relevant ICD-9 and ICD-10 codes (ICD-9-CM: R330/R338/R339; ICD 10-CM: 78,820/78821/78829) to identify women with urinary retention. According to the ICD codes, the primary categories of urinary retention encompass incomplete bladder emptying, drug-induced urinary retention, other forms of urinary retention, and unspecified urinary retention [7, 8]. The remaining women who did not suffer from urinary retention were categorised into the reference group. We assessed patient demographic characteristics, hospital characteristics, preoperative complications, and outcome metrics including LOS, total costs, and postoperative complications. Perioperative complications arising during hospitalisation were extracted from the database using ICD-9-CM diagnostic codes and the corresponding ICD-10 diagnostic codes. Intraoperative complications were defined as bladder or ureteral injury, anesthesia complications, amniotic fluid embolism, cardiac arrest, blood transfusion and uterine rupture Postoperative complications covered sepsis, deep vein thrombosis, pulmonary embolism, hemorrhage, seroma or hematoma, acute renal failure, wound rupture, postoperative shock, hysterectomy, peritonitis, severe pre-eclampsia at the end, severe puerperal infections, chorioamnionitis, respiratory failure, persistent trauma ventilation, gestational diabetes mellitus, endometritis, endometriosis and urinary retention [9]. Also, a number of confounders including type of CS, indications and other factors were included in the discussion.

Fig. 1
figure 1

Flow and inclusion/exclusion of all patients had CS

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Data analysis

We first plotted the annual incidence of postoperative urinary retention in patients undergoing CS during the study period. We then determined the baseline demographic characteristics of the patients in this case–control and compared women who developed postoperative urinary retention with those who did not. In addition, we compared these two groups of patients with respect to preoperative comorbidities, intraoperative complications, and postoperative complications. Also, a number of confounders including type of CS, indications and other factors were included in the discussion. All data analyses were performed using SPSS version 25.0 software from IBM, United States. Continuous variables are expressed as the median (lower quartile—upper quartile), while categorical variables were expressed as percentage or number of cases. We used the rank sum test or chi-square test to assess the statistical differences between the urinary retention group and the normal group in terms of demographic characteristics, hospital characteristics, preoperative comorbidities, intraoperative complications, and postoperative complications, with P < 0.05 being considered statistically significant (Table 1). Subsequently, we performed multifactorial logistic regression analyses for factors showing P < 0.05 in the rank sum test or chi-square test to assess the association between postoperative urinary retention and the variables that had been screened for, and calculated the odds ratio (OR) and its 95% confidence interval (CI) [10].

Table 1 Variables used in binary logistic regression analysis
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Results

Incidence of urinary retention in patients receiving CS in hospital

From 2010 to 2019, we obtained a total of 2,402,047 cases of CSs from the NIS database (Fig. 1). Of these, a total of 4879 patients experienced postoperative urinary retention symptoms, with a prevalence rate of 0.20% (Table 2). The annual incidence of postoperative urinary retention after CS remained relatively stable throughout the study period (Fig. 2).

Table 2 Patient characteristics and outcomes after CS (2010–2019)
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Fig. 2
figure 2

Annual incidence of postpartum urinary retention in patients undergoing CS

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Two groups of patient demographics

The mean age of patients affected by postoperative urinary retention was 1 year longer (31 vs. 30 years) compared to the unaffected population (P < 0.001) (Table 2). In addition, the maternal risk of postoperative urinary retention increased with age. Specifically, the prevalence was 4.8% higher in patients over 35 years of age (26.0% versus 21.2%, P < 0.001) (Table 2), whereas the prevalence was relatively lower in patients under 35 years of age (74% versus 78.8%, P < 0.001) (Table 2). Indian, Asian, and Pacific Islander women faced a higher risk of postoperative urinary retention compared with white women. In terms of median household income, the patient population was predominantly comprised of those with a median household income of $64,000 and above (Table 2). Furthermore, using patients with 20 ≤ body mass index (BMI) ≤ 29.9 as the reference group, the risk of postoperative urinary retention was significantly higher in women with BMI < 19.9 (0.1% versus 0.0%, P < 0.001) and BMI ≥ 40 (61.3% versus 49.7%, P < 0.001), while the risk was relatively lower in those with 30 ≤ BMI ≤ 39.9 (37.0% versus 48.7%, P < 0.001) (Table 2).

Two groups of hospital characteristics

Not surprisingly, patients with urinary retention were 2.4% less likely to be admitted to an elective hospital after CS compared to patients without these complications (54.3% vs 56.7%, P < 0.001) (Table 2). In addition, postoperative urinary retention tended to occur in teaching hospitals (74.6% vs 60.0%, P < 0.001) (Table 2). In terms of hospital region, the incidence of postoperative urinary retention was 11.6% lower in the southern region (31.0% vs 42.6%, P < 0.001) (Table 2). Meanwhile, postoperative urinary retention was more common in large hospitals (59.3% vs. 55.7%, P < 0.001) and urban hospitals (93.9% vs. 90.2%, P < 0.001) (Table 2).

Adverse outcome of urinary retention in hospital after CS

Median LOS in patients with postoperative urinary retention (3 days vs 3 days; P < 0.001) and the lower quartile were equal in LOS (4 days vs 4 days; P < 0.001), but the LOS in the upper quartile of patients with postoperative urinary retention was extended by one day (3 days vs 2 days; P < 0.001) (Table 2). This resulted in significantly higher healthcare expenditures for patients with postoperative urinary retention, with total hospital costs increasing by $23,672 ($16,274 vs $36,356; P < 0.001) (Table 2). In terms of payer type, the proportion of health insurance decreased by 6.5% (35.6% vs. 42.1%), whereas private insurance increased by 6.5% (58.3% vs. 51.8%) in the Chinese group (P < 0.001) (Table 2). In addition, there were no deaths in patients with postoperative urinary retention (P = 0.411) (Table 2).

Risk factors for urinary retention after CS

To explore risk factors associated with urinary retention, logistic regression analyses were performed and the following metrics were identified: patients between the ages of 25 and 34 years (OR = 1.27; 95% CI = 1.17–1.38; P < 0.001), patients 35 years of age and older (OR = 1.35; 95% CI = 1.22–1.48; P < 0.001), Asians and Pacific Islanders (OR = 1.85; 95% CI = 1.68–2.05; P < 0.001), one comorbidity (OR = 1.51; 95% CI = 1.28–1.79; P < 0.001), two comorbidities (OR = 1.51; 95% CI = 1.09–2.08; P = 0.013), three and more comorbidities (OR = 1.79; 95% CI = 1.06–3.04; P = 0.031), large hospitals (OR = 1.16; 95% CI = 1.07–1.26; P < 0.001), teaching hospitals (OR = 1.93; 95% CI = 1.79–2.07; P < 0.001), and hospitals in the east (OR = 1.24; 95% CI = 1.14–1.35; P < 0.001) (Table 3). Interestingly, there were two protective factors for urinary retention, namely hospitals in the south (OR = 0.76; 95% CI = 0.70–0.82; P < 0.0001) and urban hospitals (OR = 0.85; 95% CI = 0.74–0.97; P = 0.018) (Table 3).

Table 3 Risk factors associated with urinary retention after CS
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Preoperative comorbidities associated with urinary retention after CS

The above analysis shows that the presence of comorbidities is an important factor contributing to the poor prognosis of patients treated with CS. Univariate analysis showed that alcohol abuse (0.2%), nutritional anaemia (8.1%), chronic hemorrhagic anaemia (12.3%), chronic lung disease (6.5%), coagulation disorders (5.4%), depression (4.5%), diabetes mellitus (uncomplicated) (7.0%), substance abuse (1.4%), hypertension (3.6%), hypothyroidism (5.6%), liver disease (0.8%), fluid and electrolyte disorders (2.5%), metastatic cancer (0.1%), other neurological disorders (2.7%), obesity (10.7%), paralysis (0.3%), peripheral vascular disorders (0.1%), renal failure (0.2%), metastatic solid tumours without metastases (0.2%), valvular disease (0.5%), and weight loss (0.2%) accounted for a higher percentage of CS patients (Fig. 3). Multivariate logistic regression analysis revealed coagulation disorders (OR = 1.32; 95% CI = 1.08–1.61), fluid and electrolyte disorders (OR = 2.46; 95% CI = 1.94–3.11), other neurological disorders (OR = 1.51; 95% CI = 1.20–1.89), and paralysis (OR = 3.24; 95% CI = 1.95–5.38), weight loss (OR = 2.34;95% CI = 1.26–4.35) were risk factors for urinary retention, while obesity (OR = 0.69;95% CI = 0.58–0.83), substance abuse (OR = 0.53;95% CI = 0.39–0.70), and hypertension (OR = 0.58;95% CI = 0.47–0.72) were protective factors for urinary retention (Fig. 3).

Fig. 3
figure 3

Relationship between urinary retention and preoperative comorbidities

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Intraoperative and postoperative complications associated with urinary retention after CS

Intraoperative and postoperative complications are a key determinant of prognosis in patients with CS. Univariate analysis showed that CS patients with urinary retention were more likely to have bladder or ureteral injury (0.1%), blood transfusion (4.3%), uterine rupture (0.7%), sepsis (0.3%), acute renal failure (1.0%), respiratory failure (0.3%), endometritis (1.7%), deep vein thrombosis (0.1%), hemorrhage/hematoma (0.2%), hysterectomy (1.0%), peritonitis ( 0.1%), severe puerperal infection (2.0%), chorioamnionitis (6.4%) and continuous trauma ventilation (0.3%) (Fig. 4). Multivariate analysis showed that postoperative urinary retention after CS was associated with bladder or ureteral injury (OR = 6.12; 95% CI = 2.46–15.23), blood transfusion (OR = 1.51; 95% CI = 1.31–1.76), uterine rupture (OR = 1.75; 95% CI = 1.21–2.54), acute renal failure (OR = 4.74; 95% CI = 3.46–6.48), respiratory failure (OR = 2.21; 95% CI = 1.23–3.98), endometritis (OR = 1.32; 95% CI = 1.02–1.71), hemorrhage/hematoma ( OR = 2.52; 95% CI = 1.38–4.62), hysterectomy (OR = 2.30; 95% CI = 1.66–3.18), peritonitis (OR = 2.86; 95% CI = 1.03–7.92), severe puerperal infection (OR = 3.31; 95% CI = 2.60- 4.22) and chorioamnionitis (OR = 1.78; 95% CI = 1.59–2.00) had significant independent correlations (Fig. 4).

Fig. 4
figure 4

Relationship between urinary retention and intraoperative/postoperative complications

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Confounders associated with urinary retention after CS

During the research process, potential confounders, such as the type of CS and the indications for CS, may also influence the risk of urinary retention. Therefore, we conducted a comprehensive analysis to investigate their impact. Univariate analysis showed that CS patients with urinary retention were less likely to have undergone low cervical CS (97.7%) compared to classical CS (2.0%). Additionally, conditions such as cephalopelvic disproportion (2.0%), breech or other fetal position abnormalities (12.9%), placenta previa (1.1%), multiple gestation (5.6%), anatomy of the bladder (0.1%), bladder catheter placement (7.6%) and intravenous infusion (6.9%) were more common among CS patients, which may contribute to an increased risk of urinary retention (Fig. 5). Multivariate logistic regression analysis revealed that cephalopelvic disproportion (OR = 1.37; 95% CI = 1.11–1.67), breech or other fetal position abnormalities (OR = 1.10; 95% CI = 1.00–1.20), placenta previa (OR = 1.39; 95% CI = 1.06–1.84), multiple gestation (OR = 1.39; 95% CI = 1.23–1.58), anatomy of the bladder (OR = 3.93; 95% CI = 1.42–10.90), bladder catheter placement (OR = 22.57; 95% CI = 20.24–25.17) and intravenous infusion (OR = 1.22; 95% CI = 1.09–1.36) were significantly and independently associated with an increased risk of postoperative urinary retention, while low cervical CS (OR = 0.62; 95% CI = 0.50–0.76), previous CS (OR = 0.87; 95% CI = 0.82–0.93) and prolapsed cord (OR = 0.52; 95% CI = 0.31–0.86) were identified as protective factors (Fig. 5).

Fig. 5
figure 5

Relationship between urinary retention and confounders

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Discussion

In this study, we conducted a large-scale national analysis aimed at exploring the health-economic consequences of urinary retention after CS. As the first broad survey on the subject in the country, we assessed the prevalence of urinary retention after CS at the national level and analyzed its health-economic consequences. The overall incidence of urinary retention between 2010 and 2019 was 0.20%. This figure may seem low, and we believe there are several main reasons for this: first, the results of this study were based primarily on the NIS database, and patients were predominantly white. Whereas analysis of the data suggests that Indian, Asian, and Pacific Islander women are at higher risk for postoperative urinary retention, this population composition may contribute to the lower overall prevalence of urinary retention [11, 12]. Secondly, clinicians' lack of awareness of urinary retention has resulted in urinary retention not being recorded and managed in a timely manner, which has led to a low statistical prevalence of urinary retention [4, 13]. Finally, due to differences in definitions of urinary retention, studies based on different criteria have produced different results. In the NIS database, urinary retention is defined as a phenomenon in which urine cannot be excreted normally, resulting in a buildup of urine in the bladder, while it is not defined as such in other studies. Consequently, studies of urinary retention using ICD-9 or ICD-10 codes as an identifying criterion yielded relatively low rates of urinary retention, whereas studies using other identifying criteria reported higher rates of urinary retention, a difference that resulted in significant fluctuations in urinary retention prevalence across studies [4, 11, 12, 14]. However, the prevalence of urinary retention is on the rise, from 0.12% to 0.33%, a change that highlights the urgency of implementing effective preventive measures to reduce the incidence of this complication.

These include optimising anaesthetic and analgesic regimens, encouraging early maternal mobility, retraining bladder function, and avoiding prolonged bed rest. Furthermore, in addition to the identified factors that may contribute to the difference in incidence, the continued increase in the rate of CSs may be an important factor, as it increases the overall number of patients undergoing CSs [4]. Of all the complications, gestational diabetes mellitus is the leading complication of post-CS with urinary retention, closely followed by chorioamnionitis, transfusion requirements and severe puerperal infections [15].

In agreement with the results of several previous studies [9, 16, 17], this study confirms the positive correlation between increasing age and the risk of urinary retention after CS. Specifically, the mean age of patients who suffered urinary retention was approximately 1 year higher than that of patients who did not. Further analyses showed that the prevalence of urinary retention was significantly higher in patients aged 35 years and older than in the group of patients younger than 35 years. Using logistic regression analysis, we found that patients aged 25 to 34 years and 35 years and older were more likely to experience urinary retention after CS compared to patients under 25 years of age, and these two age groups were identified as independent risk factors for urinary retention.

In addition, the study observed a higher proportion of Asian and Pacific Islander patients with urinary retention, and this group was also identified as a significant risk factor for urinary retention in logistic regression analyses. This phenomenon may be related to recent changes in United States payment policy, which may have led to a decrease in CS rates among white women [18]. On an economic level, this study found that patients with median household incomes of $64,000 and above were more commonly in the CS group, which may be related to the higher healthcare costs associated with CS compared with normal delivery [19].

Furthermore, the study found that women with BMI < 19.9 and BMI ≥ 40 had a significantly higher risk of urinary retention, while those with 30 ≤ BMI ≤ 39.9 had a relatively lower risk. This phenomenon may be associated with the significant slowing effect of malnutrition (due to low BMI) on drug metabolism, including anesthetics, leading to prolonged anesthetic effects postoperatively and longer recovery times for malnourished patients compared to those with normal nutritional status [20, 21]. For patients with higher-than-normal BMI, the incidence of urinary retention after CS may be influenced by multiple factors, including obesity and the surgeon's preference for CS, although the exact mechanisms remain to be elucidated. These findings suggest that factors such as the patient's age, race, economic status, and BMI should be taken into account when assessing the risk of urinary retention after CS [22].

After a critical analysis, we found that patients admitted for elective CS had a relatively low risk of postpartum urinary retention, a phenomenon that is not surprising. This lower risk may be related to the lower incidence of complications among elective admission patients themselves, in contrast to patients undergoing emergency CS, who face a higher risk of maternal and neonatal complications [23]. In addition, our findings suggest that elective admission is a protective factor against urinary retention, a finding that further supports the above.

In exploring the plausibility of teaching hospitals as a predictor of postoperative urinary retention risk, we found that postoperative complications were more common in hospitals with residents involved in surgical care. As a result, teaching hospitals tended to exhibit higher risk-adjusted rates of serious complications and readmissions compared with non-teaching hospitals [24, 25]. In performing logistic regression analyses, we found that both teaching hospitals and large hospitals were identified as risk factors for urinary retention. The fact that large hospitals are a risk factor may be related to the fact that they admit more severely ill patients, have a higher proportion of elderly patients, and that patients with complex comorbidities are more likely to be referred to these hospitals, which together contribute to the poorer prognosis of patients in large hospitals [26].

In terms of geographical distribution, our study showed that southern and urban hospitals were protective factors for urinary retention, whereas western hospitals were considered risk factors for urinary retention. Although the exact causes are not yet clear, multifactorial interactions may be involved. Differences in regional and hospital characteristics may be attributable in part to variations in resource allocation, obstetric practice, and surgical care management processes, as well as factors that may not be captured by current databases, such as regional differences in data collection and reporting, geographic differences, and patient characteristics. Therefore, further in-depth studies on the higher risk of urinary retention in hospitals in the south and urban areas and the lower risk in hospitals in the west are needed to explore the potential impact of resource allocation, obstetric practice, hospital management, and population or socio-demographic characteristics [27].

The results of this study show a correlation between the occurrence of urinary retention and prolonged LOS after CS. Prolonged LOS may be due to a variety of postoperative factors including, but not limited to, the occurrence of postoperative complications, the complexity of pain management, the patient's return to ambulation, and the availability of family support [28, 29]. Additionally, this study observed an increase in total healthcare costs due to the prolonged hospital stay and the high cost of CS itself. It is worth pointing out that no deaths directly attributable to urinary retention were recorded in the sample of this study, which may indicate that the severity of urinary retention and its direct impact on the life safety of the patient is limited within the scope of observation of this study [30].

In order to effectively reduce and improve the incidence of urinary retention, a challenging complication after CS, the key lies in the accurate preoperative identification of high-risk patient groups [5, 6, 9, 16,17,18]. This study specifically highlights coagulation disorders (OR = 1.32) as a significant risk factor for urinary retention, suggesting that it plays an important role in the development of postoperative urinary retention. As pointed out by F. Gary Cunningham and other researchers, coagulation disorders are a non-negligible factor in post-CS complications, which are associated with an increased risk of serious complications such as a variety of obstetric hemorrhages, hematoma formation, placental abruption, microthrombosis, amniotic fluid embolism, sepsis syndromes, as well as acute fatty liver disease in pregnancy [31, 32]. In addition, previous studies have shown that hematoma formation following bleeding is a trigger for the development of urinary retention [33, 34]. Specifically, if the hematoma is located below the levator plate, the bleeding may extend to the hip area and may spread ventrally into the parvesical space, pressing on the urethra or the neck of the bladder, causing mechanical obstruction and resulting in urinary retention. Therefore, careful preoperative assessment and management of patients with coagulation abnormalities is important for the prevention of urinary retention and its associated complications.

The association between fluid and electrolyte disturbances (OR = 2.46) and urinary retention was significant [35,36,37]. Possible mechanisms for this association include the effect of electrolyte disturbances on the function of the detrusor muscle of the bladder, which in turn leads to reduced bladder emptying capacity [35, 36]. Specifically, electrolyte disturbances may impair the contractility of the detrusor muscle of the bladder, as electrolyte balance is critical for maintaining normal muscle function. In addition, electrolyte disturbances may also affect kidney function, which plays a central role in the regulation of electrolyte balance. Any impairment of renal function may result in impaired urine production and excretion, which may increase the risk of urinary retention [36, 37].

Further, other neurological conditions (OR = 1.51) and paralysis (OR = 3.24) were also associated with an increased risk of urinary retention. These conditions may result in motor and sensory dysfunction, which in turn affects neurological control of the bladder and urethral sphincter. This loss of control may lead to a decrease in bladder detrusor contractility or dysfunctional urethral sphincter synergy, which ultimately prevents effective bladder emptying and thus increases the risk of urinary retention [38,39,40]. Thus, together, these factors may play an important role in the development of urinary retention.

After in-depth analyses, we unexpectedly found that weight loss (OR = 2.34) was significantly associated with an increased risk of urinary retention, whereas obesity (OR = 0.69) showed a protective effect against urinary retention. In addition, substance abuse (OR = 0.53) and hypertension (OR = 0.58) were also identified as protective factors for urinary retention. Although the exact mechanism remains to be elucidated, this finding may be related to the small number of patients with specific indications in the study sample, who were minimally avoided during surgery because they were considered a high-risk group for post-CS complications [22, 41, 42]. Therefore, these results may require further validation in a larger sample to accurately assess the true association between these factors and the risk of urinary retention.

After exploring the relationship between preoperative comorbidities such as coagulation disorders, fluid and electrolyte disorders, other neurological disorders, paralysis and the risk of urinary retention, we further analyzed the complications during and after CS. These complications not only affect the patient's recovery process, but may also reveal potential risks associated with preoperative health status. In the following, we will discuss these intraoperative and postoperative complications in detail and explore their association with preoperative comorbidities.

Reproductive system complications are particularly common after CS. Chorioamnionitis (OR = 1.78) is one of the most common infection-related diagnoses in labour and delivery rooms [3, 43, 44]. This phenomenon may be related to cervical dilatation and rupture of the membranes during CS, operations that increase the opportunity for microorganisms in the vaginal vault to colonise the uterine cavity. In addition, instrumentation and insertion of foreign bodies into the uterine cavity increase the risk of uterine infections in the postpartum period. Chorioamnionitis is not only a puerperal antecedent to infections such as endometritis (OR = 1.32) and peritonitis (OR = 2.86), but also increases the risk of developing serious infections in the postpartum period [44,45,46].

Digestive complications, especially uterine rupture, are a major challenge after CS. Uterine scar formation after previous CS is the most common risk factor for uterine rupture (OR = 1.75). Scar tissue may not be as tough as normal myometrium, thus making it more susceptible to uterine rupture during labour. In addition to scar tissue, abnormal foetal position during CS and obstructed labour significantly increase the likelihood of uterine rupture, and in severe cases hysterectomy may be required (OR = 2.30) [3, 47, 48].

An increased risk of circulatory disorders and urological disorders was associated with coagulation disorders (OR = 1.32), one of the preoperative risk factors for urinary retention. Coagulation disorders are disorders in which the blood coagulates abnormally, and patients with preoperative coagulation disorders may be more likely to bleed during and after surgery, and in severe cases develop hematomas, which may require blood transfusions to correct coagulation abnormalities and replace blood loss [31, 49, 50]. Postoperative hemorrhage/hematoma (OR = 2.52), blood transfusion (OR = 1.51) and acute renal failure (OR = 4.74) were the main complications associated with coagulation disorders. In addition, the association between coagulation disorders and acute renal failure has been reported in previous studies [51, 52]. Therefore, preventing the development of coagulation disorders and providing timely treatment are important ways to reduce the incidence of acute renal failure in patients with CS.

Moreover, during CS, emergency surgical maneuvers required for massive hemorrhage—often urgent, abrupt, and stress-inducing—may cause bladder or ureteral injury (OR = 6.12) during peritoneal incision [53, 54]. This risk is exacerbated by the complexity and time-sensitive nature of the operative environment, as anatomical displacement or obscured visualization under emergency conditions increases the likelihood of iatrogenic injury.

The contribution of neurological disorders to the development of urinary retention in patients with CS is also of interest. In our study, other neurological disorders (OR = 1.51) were identified as risk factors for urinary retention. Neurological disorders are strongly associated with respiratory complications, and patients with certain neurological disorders have an increased risk of developing chest infections and respiratory failure (OR = 2.21) due to muscle weakness. In particular, patients with certain neuromuscular disorders are at higher risk [55].

Through in-depth analyses of these complications, we have gained a more comprehensive understanding of the risks faced by patients following CS, thereby enabling the development of targeted prevention and treatment strategies. For patients with coagulation disorders, perinatal transfusion of coagulation factors to maintain near-normal prothrombin activity, coupled with careful consideration of intrathecal anaesthesia and thorough risk disclosure to the patient, can significantly mitigate the risk of urinary retention [56]. Timely correction of electrolyte imbalances, such as hypokalaemia and hypocalcaemia, is crucial for maintaining a stable internal environment in patients with fluid and electrolyte disturbances [57]. Furthermore, for patients with neurological disorders or paralysis, precise selection of anaesthesia and surgical methods, along with personalised postoperative care, can effectively reduce the incidence of urinary retention [57]. Appropriate nutritional support and weight gain are also important interventions for patients experiencing weight loss [57]. Collectively, early identification of high-risk factors and judicious arrangements for hospitalisation are essential in reducing the incidence of urinary retention.

In this study, we identified several potential confounders that may influence the risk of urinary retention following CS, including the type of CS and the indications for the procedure. Our findings revealed that patients who underwent low cervical CS were significantly less likely to develop urinary retention (97.7%) compared to those who underwent classical CS (2.0%). This suggests that the surgical approach may play a crucial role in the development of postoperative urinary retention, with low cervical CS potentially offering a protective effect due to its less invasive nature and reduced risk of bladder or ureteral injury [58, 59].

Additionally, we observed that certain clinical conditions, such as cephalopelvic disproportion (2.0%), breech or other fetal position abnormalities (12.9%), placenta previa (1.1%), and multiple gestation (5.6%), were more prevalent among CS patients who developed urinary retention. These conditions may contribute to an increased risk of urinary retention by complicating the surgical procedure and increasing the likelihood of bladder or ureteral trauma [60,61,62]. Furthermore, anatomical factors such as bladder anatomy (0.1%) and procedural factors like bladder catheter placement (7.6%) and intravenous infusion (6.9%) were also associated with a higher risk of urinary retention [63, 64]. These findings highlight the importance of careful preoperative assessment and intraoperative management to minimize the risk of urinary retention in high-risk patients.

The protective effect of low cervical CS may be attributed to its reduced risk of inducing bladder or ureteral injury, as well as its association with fewer postoperative complications [58, 59]. Notably, in cases of prolapsed cord, the clinical urgency typically necessitates immediate CS to prevent fetal hypoxia and mortality, thereby significantly abbreviating the duration of labor. This rapid intervention minimizes prolonged mechanical compression on the bladder and urethral structures, consequently mitigating the likelihood of postoperative urinary retention [62, 65]. Interestingly, previous CS demonstrates an unexpected protective effect against urinary retention, potentially explained by heightened clinical vigilance toward this high-risk population during surgical procedures, with surgeons implementing meticulous surgical techniques to prevent iatrogenic bladder trauma [66, 67].

While we have made every effort to include and analyze as many relevant variables as possible, the NIS database has inherent limitations. Specifically, certain variables—such as the duration of surgery, type of anesthesia, type and volume of intravenous fluids (both intraoperative and postoperative), timing of catheter removal, medications administered during and after surgery, dosage and medications used in epidural cases, timing of epidural catheter removal, time to ambulation, time to oral feeding, and time to breastfeeding—were not documented. To address these limitations, we supplemented our analysis with insights from existing literature, aiming to contextualize the observed associations within a broader evidence framework.

Prolonged surgical duration, particularly during the second stage of labor, exacerbates bladder dysfunction through mechanical compression of pelvic nerves and bladder mucosa edema, consistent with the observed association between intraoperative complications (e.g., bladder injury, OR = 6.12) and postoperative urinary retention [64, 68]. This mechanical stress may compound the effects of preexisting neurological disorders (OR = 1.51) or paralysis (OR = 3.24), which independently impair detrusor contractility.

The type and dosing of anesthesia significantly modulate postoperative urinary retention risk. Neuraxial anesthesia, especially intrathecal morphine, delays bladder recovery by suppressing sacral parasympathetic pathways, mirroring the study’s findings of increased complications like acute renal failure (OR = 4.74) and respiratory failure (OR = 2.21) in postoperative urinary retention cases [64, 68]. Higher concentrations of epidural local anesthetics (e.g., ropivacaine 0.1%) synergize with opioids to exacerbate urethral sphincter dysfunction, potentially explaining the elevated morbidity in teaching hospitals (OR = 1.93), where complex analgesic protocols are more common [64].

Intraoperative fluid overload (> 750 mL) directly correlates with postoperative urinary retention risk, likely through bladder overdistension and detrusor muscle injury. This aligns with the study’s identification of fluid/electrolyte disorders as a major risk factor (OR = 2.46) [64]. Postoperative fluid management further modulates outcomes: sodium-rich solutions may worsen urethral edema, whereas balanced crystalloids (e.g., lactated Ringer’s) could mitigate this risk, though this requires validation against the study’s urban hospital data (protective OR = 0.85).

Catheter removal timing critically balances bladder recovery and infection risks. Early removal (< 6 h post-CS) may coincide with residual anesthetic effects (e.g., intrathecal morphine’s 12-h half-life), while delayed removal increases urinary tract infections, indirectly elevating postoperative urinary retention risk through inflammatory pathways [63, 69, 70]. The study’s reported association between postoperative urinary retention and severe puerperal infections (OR = 3.31) supports this mechanistic link.

Early ambulation (< 6 h post-CS) and oral intake promote neurological recovery and bladder reflex reactivation, potentially reducing LOS (prolonged in postoperative urinary retention cases, P < 0.001) and costs [71,72,73,74]. These interventions may counterbalance risk factors like advanced maternal age (OR = 1.35 for ≥ 35 years) and Asian/Pacific Islander ethnicity (OR = 1.85), possibly by enhancing physiological recovery.

These findings underscore the multifactorial nature of postoperative urinary retention pathogenesis, where surgical, pharmacological, and postoperative care variables interact with patient-specific factors (e.g., comorbidities, OR = 1.51–1.79) to determine outcomes. Targeted strategies—including optimized anesthesia protocols, fluid restriction, and early mobilization—could mitigate postoperative urinary retention incidence, particularly in high-risk populations identified in the nationwide study.

This study faced several inherent limitations in utilising the NIS database for analysis. Firstly, the NIS database only records information about patients during their hospitalisation and fails to cover post-discharge complications or outcomes, such as readmission rates and long-term follow-up data, which may lead to underestimation of the prevalence of urinary retention as the study was only able to capture early hospitalisation cases [75]. Second, the study relied exclusively on medical billing data from the NIS database, and possible coding inconsistencies in the data may affect the robustness of the multivariate model, which in turn may affect the accurate capture of observed trends in complications. Thirdly, the analysis was limited by the variables recorded in the NIS database and lacked other risk factors known to be associated with urinary retention, such as surgical manipulation, type of anaesthesia, duration of tube placement, duration of surgery, American Society of Anesthesiologists (ASA) score, serum albumin level, immobility and skin movement [16, 76]. Additionally, similar to any large administrative database, there may be discrepancies or misclassifications in the coding and documentation in the NIS database [77]. Nonetheless, the NIS database remains valuable as a broad and representative national database for identifying trends and demographics and is widely used as a reliable research tool [7]. Its validity has been demonstrated through validation with other databases, particularly in accurately identifying patients undergoing specific orthopaedic procedures [10].

Conclusion

In this study, we found an overall prevalence of 0.20% for urinary retention after CS and identified a range of factors associated with an increased risk of urinary retention, including maternal age between 25 and 34 years, 35 years and older, Asian and Pacific Islander background, presence of comorbidities, delivery in a large hospital or teaching hospital, hospitals located in the Eastern region, coagulation disorders, fluid and electrolyte disorders, other neurological disorders, paralysis, and weight loss. Comparatively, hospitals in the southern region, urban hospitals, obesity, substance abuse, and hypertension were considered protective factors that reduced the risk of urinary retention. Patients experiencing urinary retention tend to be associated with more postoperative comorbidities, prolonged LOS, and higher total healthcare costs. Several confounders also significantly influenced the incidence of urinary retention. Therefore, despite the relatively low prevalence of urinary retention, healthcare professionals need to devote more attention and resources to identifying patients who undergo CS and are at increased risk of urinary retention, and to develop effective management strategies to mitigate adverse outcomes in these patients. We recommend that relevant risk factors be identified through antenatal screening, and that elective admissions should be arranged to avoid emergency CSs for women with comorbidities, coagulation disorders, fluid and electrolyte disturbances, other neurological disorders or paralysis, among other problems. At the same time, these risk factors should be intervened in the antenatal period and signs of associated complications should be closely monitored in the postnatal period to reduce the incidence of urinary retention.

Data availability

This study is based on data provided by Nationwide Inpatient Sample (NIS) database, part of the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. The NIS database is a large publicly available full-payer inpatient care database in the United States and the direct web link to the database is https://www.ahrq.gov/data/hcup/index.html. Therefore, individual or grouped data cannot be shared by the authors.

Abbreviations

CS:

Cesarean section

NIS:

National Inpatient Sample

LOS:

Length of stay

AHRQ:

Agency for Healthcare Research and Quality

ICD-9-CM:

International Classification of Diseases Ninth Revision, Clinical Modification Codes

ICD-10-CM:

International Classification of Diseases Tenth Revision, Clinical Modification Codes

ICD-9:

International Classification of Diseases Ninth Revision

ICD-10:

International Classification of Diseases Tenth Revision

OR:

Odds ratio

CI:

Confidence interval

BMI:

Body mass index

ASA:

American Society of Anesthesiologists

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Acknowledgements

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Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Author notes

  1. Fufei Zhang, Jingyi Huang and Xinlin Huang contributed equally to this work.

Authors and Affiliations

  1. School of Health, Dongguan Polytechnic, Dongguan, Guangdong, 523000, China

    Fufei Zhang

  2. School of Pharmaceutical Sciences, Southern Medical University, Guangzhou, Guangdong, 510515, China

    Jingyi Huang

  3. The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, 510515, China

    Xinlin Huang & Xinran Zhao

  4. Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China

    Qinfeng Yang & Jian Wang

  5. Department of Laboratory Medicine, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, 510000, China

    Xuegao Yu

  6. Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China

    Xue Xu

Authors
  1. Fufei Zhang
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  7. Xuegao Yu
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Contributions

F.Z., J.H. and X.H. contributed to the literature review, data collection, statistical analysis, data interpretation, manuscript writing, preparation of figures and tables. X.Z. and Q.Y. participated in the design of the study and helped the statistical analysis. X.Y., X.X. and J.W. contributed to approval of the final work. The author(s) read and approved the final manuscript.

Corresponding authors

Correspondence to Jian Wang, Xuegao Yu or Xue Xu.

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Ethics approval and consent to participate

This article does not involve any research on human participants or animals. This observational study used the National Inpatient Sample (NIS) database, a publicly available, research-specific dataset. As is the case with other studies utilizing the NIS, this study did not require ethical review, as the data are anonymised and cannot be linked to any individuals. The NIS dataset has been rigorously desensitised to ensure the security of individual privacy. Researchers use these data solely for statistical analyses or scientific research, with no direct impact on individuals. Therefore, in accordance with relevant ethical review regulations, no consent from individuals is required [78,79,80].

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Zhang, F., Huang, J., Huang, X. et al. Incidence and risk factors of postpartum urinary retention following cesarean section: a retrospective nationwide inpatient sample database study. BMC Women's Health 25, 180 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-025-03728-w

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-025-03728-w

Keywords

BMC Women's Health

ISSN: 1472-6874

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