A 37-year-old woman presents with an inability to void in the hours after giving birth to her first child via vaginal delivery. Her delivery involved the use of epidural anesthesia as well as pelvic trauma from the use of forceps. She is currently experiencing urinary leakage and complains of increased lower abdominal pressure. Which of the following is the most appropriate treatment for this patient’s condition?

Pelvic floor muscle strengthening

A 40-year-old woman was admitted to the surgical service after an uncomplicated appendectomy. She underwent surgery yesterday and had an uneventful postoperative course. However, she now complains that she is unable to completely void. She also complains of pain in the suprapubic area. You examine her and confirm the tenderness and fullness in the suprapubic region. You ask the nurse to perform a bladder scan, which reveals 450cc. What is the next appropriate step in management?

Neostigmine methylsulfate injection

Intravenous neostigmine methylsulfate

A 58-year-old man presents to the Emergency Department after 3 hours of intense suprapubic pain associated with inability to urinate for the past day or two. His medical history is relevant for benign prostatic hyperplasia (BPH) that has been under treatment with prazosin and tadalafil. Upon admission, he is found to have a blood pressure of 180/100 mm Hg, a pulse of 80/min, a respiratory rate of 23/min, and a temperature of 36.5°C (97.7°F). He weighs 84 kg (185.1 lb) and is 175 cm (5 ft 7 in) tall. Physical exam, he has suprapubic tenderness. A bladder scan reveals 700 ml of urine. A Foley catheter is inserted and the urine is drained. Initial laboratory tests and their follow up 8 hours after admission are shown below. Admission 8 hours after admission Serum potassium 4.2 mmol/L Serum potassium 4.0 mmol/L Serum sodium 140 mmol/L Serum sodium 142 mmol/L Serum chloride 102 mmol/L Serum chloride 110 mmol/L Serum creatinine 1.4 mg/dL Serum creatinine 1.6 mg/dL Serum blood urea nitrogen 64 mg/dL Serum blood urea nitrogen 62 mg/dL Urine output 250 mL Urine output 260 mL A senior attending suggests a consultation with Nephrology. Which of the following best justifies this suggestion?

Estimated glomerular filtration rate (eGFR)

Serum blood urea nitrogen (BUN)

A 40-year-old sailor is brought to a military treatment facility 20 minutes after being involved in a navy ship collision. He appears ill. He reports a sensation that he needs to urinate but is unable to void. His pulse is 140/min, respirations are 28/min, and blood pressure is 104/70 mm Hg. Pelvic examination shows ecchymoses over the scrotum and perineum. There is tenderness over the suprapubic region and blood at the urethral meatus. Digital rectal examination shows a high-riding prostate. Abdominal ultrasound shows a moderately distended bladder. X-rays of the pelvis show fractures of all four pubic rami. Which of the following is the most likely cause of this patient's symptoms?

Tearing of the posterior urethra

Tearing of the anterior urethra

Rupture of the corpus cavernosum

A 63-year-old man undergoes uncomplicated laparoscopic cholecystectomy for acute cholecystitis and is admitted to the surgical ward for postoperative management. On postoperative day 1, routine laboratory studies reveal an increase in serum creatinine to 1.46 mg/dL from 0.98 mg/dL before the operation; BUN is 37 mg/dL, increased from 18 mg/dL on prior measurement; K is 4.8 mEq/L and CO2 is 19 mEq/L. The patient has an indwelling urinary catheter in place, draining minimal urine over the last few hours. Which of the following is the most appropriate next step in management?

Evaluate urinary catheter for obstruction

Obtain bilateral renal ultrasonography

Three hours after undergoing open proctocolectomy for ulcerative colitis, a 42-year-old male complains of abdominal pain. The pain is localized to the periumbilical and hypogastric regions. A total of 20 mL of urine has drained from his urinary catheter since the end of the procedure. Temperature is 37.2°C (98.9°F), pulse is 92/min, respirations are 12/min, and blood pressure is 110/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 99%. Physical examination shows a 20 cm vertical midline incision and an ileostomy in the right lower quadrant. There is no fluid drainage from the surgical wounds. The urinary catheter flushes easily and is without obstruction. Cardiopulmonary examination shows no abnormalities. Serum studies show a blood urea nitrogen of 30 mg/dL and a creatinine of 1.3 mg/dL. Which of the following is the most appropriate next step in management?

Administer intravenous furosemide

A 55-year-old man presents to his primary care physician for a wellness checkup. The patient has a past medical history of alcohol abuse and is currently attending alcoholics anonymous with little success. He is currently drinking roughly 1L of hard alcohol every day and does not take his disulfiram anymore. Which of the following findings is most likely to also be found in this patient?

Increased transketolase activity

Urinary complications for USMLE Step 1: High-Yield Surgery Lessons

Postoperative Urinary Retention - Can't Pee, Can't Leave

Etiology: A common complication from detrusor muscle suppression via anesthesia (especially spinal/epidural), opioids, and anticholinergics. Bladder overdistension further impairs contractility.
Risk Factors: Male gender, benign prostatic hyperplasia (BPH), advanced age, and prolonged pelvic or hernia repair surgeries.
Diagnosis & Management:

⭐ Bethanechol is generally avoided in the immediate postoperative period for treating retention, as it can increase bladder pressure against a potentially obstructed outlet and cause systemic side effects.

Normal vs. Abnormal Post-Void Residual Volume Ultrasound

Postoperative UTI - The Unwanted Souvenir

Etiology: Most common nosocomial infection, primarily from indwelling catheters (CAUTI). Common organisms: E. coli, Klebsiella, Enterococcus.
Risk Factors: ↑ catheter duration, female sex, elderly, diabetes.
Symptoms: Fever, dysuria, urgency, suprapubic pain. Delirium in the elderly.
Diagnosis: Urinalysis (pyuria >10 WBCs/hpf, nitrites). Urine culture is definitive (>10^3 CFU/mL with symptoms).
Management: Remove/change catheter. Treat symptomatic patients only with antibiotics (e.g., ceftriaxone).

⭐ The single most important risk factor for CAUTI is the duration of catheterization. Remove catheters as soon as they are no longer indicated.

Postoperative AKI - Kidneys On Strike

Kidney and nephron anatomy with AKI cause locations

Presentation: ↓ Urine output (< 0.5 mL/kg/hr) & ↑ Serum Creatinine.
Etiology is key:
- Prerenal (most common): Hypovolemia (hemorrhage, dehydration), ↓ cardiac output.
- Intrinsic: Acute Tubular Necrosis (ATN) from prolonged ischemia or nephrotoxins (contrast, aminoglycosides).
- Postrenal: Urinary tract obstruction (e.g., blocked Foley catheter).

⭐ In prerenal states, Fractional Excretion of Sodium (FENa) is <1% due to avid sodium reabsorption by healthy tubules. In ATN, damaged tubules can't reabsorb, so FENa is >2%.

Iatrogenic Injury - A Surgical Oopsie

Most common during pelvic surgery, esp. hysterectomy ("water under the bridge"-uterine artery over ureter).
Presentation:
- Intra-op: Direct visualization.
- Post-op: Flank pain, fever, oliguria, watery vaginal discharge (fistula).
Diagnosis:
- Labs: ↑ Cr.
- Imaging: CT urogram is the test of choice. Retrograde cystogram for bladder injury.
Management:
- Intra-op: Immediate primary repair.
- Delayed: Percutaneous nephrostomy or ureteral stenting, then delayed repair.

⭐ Post-hysterectomy, a sudden gush of clear vaginal fluid suggests a vesicovaginal or ureterovaginal fistula.

High-Yield Points - ⚡ Biggest Takeaways

Postoperative urinary retention (POUR) is common after spinal anesthesia or pelvic surgery. Diagnose with a bladder scan; treat with catheterization for volumes >400 mL.

Catheter-associated UTIs (CAUTIs) are a leading cause of nosocomial infection; prompt catheter removal is the most effective preventive measure.

Iatrogenic ureteral injury is a risk in colorectal and gynecologic surgery. Suspect it with postoperative fever or flank pain.

Bladder dome rupture can cause chemical peritonitis from urine in the abdomen.

Postoperative AKI is most often pre-renal from hypovolemia, but always rule out post-renal obstruction.

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