Gross Hematuria with Clot Retention (AUA 2020)

Algorithm Steps

1. ▶

   Start

   Gross Hematuria with Clot Retention

   Unable to void due to blood clots, or significant hematuria

   1. ●

      Action

      Initial Assessment

      Evaluate hemodynamic status and cause

      • Vital signs - assess for hypovolemia
      • Time since last void
      • Anticoagulant/antiplatelet use
      • Recent procedures (TURP, biopsy, cystoscopy)
      • Known malignancy?
      • Trauma history?
      • Labs: CBC, BMP, coags, type & screen
      1. ◆

         Decision

         Hemodynamically Stable?

         Signs of significant blood loss?

         1. ⚠

            Warning

            ⚠️ Resuscitate First

            Address hemodynamic instability

            • IV access x2, fluid resuscitation
            • Type & crossmatch, transfuse if needed
            • Hold anticoagulation if possible
            • Reverse anticoagulation if life-threatening
            • Urology STAT consult
            1. ●

               Action

               Place Large Bore 3-Way Catheter

               ≥22 Fr hematuria catheter

               • 22-24 Fr 3-way Foley catheter
               • Larger lumen for clot passage
               • 30mL balloon
               • Hematuria catheters have reinforced lumen
               • If existing catheter, may need to upsize
               1. ●

                  Action

                  Manual Clot Evacuation

                  MUST do before starting CBI

                  • Use Toomey syringe (60mL) or Ellik evacuator
                  • Irrigate with normal saline
                  • Aspirate clots manually
                  • Repeat until returns are clear/light pink
                  • CBI does NOT break up clots - must evacuate first
                  • May take multiple irrigation cycles
                  1. ◆

                     Decision

                     Clots Successfully Evacuated?

                     Returns clear or light pink

                     1. ●

                        Action

                        Initiate Continuous Bladder Irrigation

                        Prevent new clot formation

                        • Normal saline irrigation bags (2-4L)
                        • Connect to inflow port of 3-way catheter
                        • Large drainage bag on outflow
                        • Start at rapid rate, then titrate
                        • Goal: Clear to light pink output
                        • Typical rate: 1-2 L/hour initially
                        1. ●

                           Action

                           CBI Monitoring

                           Continuous assessment

                           • Monitor urine color every 15-30 min initially
                           • Adjust rate to maintain light pink
                           • Check for catheter blockage hourly
                           • Record true urine output (output - irrigant)
                           • Watch for bladder distension (blocked catheter)
                           • Hand irrigate PRN if clots recur
                           1. ⚠

                              Warning

                              ⚠️ CBI Precautions

                              Critical monitoring points

                              • If inflow >> outflow: STOP - likely blocked
                              • Risk of bladder rupture if obstructed
                              • Contraindicated if bladder perforation suspected
                              • Monitor for hypothermia (cold irrigant)
                              • Daily labs if ongoing significant bleeding
                              1. ●

                                 Action

                                 Evaluate Underlying Cause

                                 Once stable, investigate etiology

                                 • CT urogram (once stable)
                                 • Cystoscopy if not already done
                                 • Common causes: BPH, malignancy, stones, infection
                                 • Post-procedural (TURP, biopsy)
                                 • Anticoagulation-related
                                 • Trauma
                                 1. ✓

                                    Outcome

                                    Hematuria Controlled

                                    Wean CBI when urine clear for 24h

                                    • Gradually decrease CBI rate
                                    • D/C CBI when clear x24h
                                    • Trial of void after catheter removal
                                    • Outpatient follow-up for cause evaluation
                                 2. ✓

                                    Outcome

                                    Requires Intervention

                                    Operative management needed

                                    • TUR of bleeding tumor/vessel
                                    • Embolization for refractory bleeding
                                    • Nephrectomy if upper tract source uncontrolled
                                    • Address malignancy if present
                     2. ●

                        Action

                        Operative Cystoscopy

                        Clot evacuation + source control

                        • Failure of bedside evacuation
                        • OR for cystoscopy with Ellik evacuator
                        • Identify bleeding source
                        • Fulguration of bleeding vessels
                        • May need TUR of bleeding tumor
                        • Consider arteriography/embolization if refractory