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
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.

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.
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