What is the treatment for acute urinary retention due to hematuria with blood clots?

From the Guidelines

The treatment of acute urinary retention due to hematuria with blood clots requires prompt bladder decompression through catheterization with a large-bore catheter (typically 20-24 French three-way Foley catheter). This approach is crucial in relieving the obstruction caused by blood clots and preventing further complications such as bladder rupture or worsening renal function.

Key Considerations

• Once the catheter is placed, continuous bladder irrigation (CBI) should be initiated using sterile normal saline at a rate sufficient to maintain clear or light pink drainage, as evidenced by general medical knowledge and not specifically mentioned in 1 or 1.
• Manual bladder irrigation may be necessary initially to evacuate large clots using a 60 mL catheter-tip syringe with gentle instillation and aspiration of 30-50 mL aliquots of saline.
• If clots cannot be evacuated by irrigation, cystoscopy with clot evacuation may be required, highlighting the importance of urological intervention in managing such cases.
• Pain management with analgesics such as oxycodone 5-10 mg every 4-6 hours or ketorolac 30 mg IV (if no contraindications) helps relieve discomfort, although specific pain management strategies are not discussed in 1 or 1.
• Addressing the underlying cause of hematuria is essential, which may include treating infections with appropriate antibiotics, managing anticoagulation if present, or addressing urological conditions like bladder tumors or stones, as suggested by the holistic approach to treatment mentioned in 1.
• Hemostatic agents such as tranexamic acid (1 gram IV or PO three times daily) may help control bleeding, based on general medical principles rather than specific guidance from 1 or 1.
• Monitoring hemoglobin levels and maintaining hemodynamic stability with IV fluids or blood transfusions may be necessary in cases of significant blood loss.
• The catheter should remain in place until hematuria resolves and normal voiding can resume, typically for 24-72 hours depending on the severity and underlying cause, reflecting a balance between the need for continuous drainage and the risks associated with prolonged catheterization, not explicitly stated in 1 or 1 but informed by clinical practice.

Underlying Principles

• The use of treatments with a strong evidence base for their clinical effectiveness is emphasized in 1, underscoring the importance of evidence-based practice in managing acute urinary retention due to hematuria with blood clots.
• While 1 discusses urinary retention in the context of stroke rehabilitation, its recommendations for intermittent catheterization as initial management do not directly apply to the scenario of acute urinary retention due to hematuria with blood clots, highlighting the need to consider the specific clinical context when applying guidelines.

From the Research

Treatment Options for Acute Urinary Retention due to Hematuria with Blood Clots

• The management of urinary clot retention and hematuria involves manual irrigation with sterile water or normal saline via a Foley catheter followed by continuous bladder irrigation 2.
• Tissue plasminogen activator (t-PA/Alteplase) may be a useful pharmacological agent to improve the efficacy of manual irrigation of large, dense clots 2.
• A study found that clot evacuation with 25 mL of t-PA at a concentration of 2 mg/mL was significantly easier and faster than the sterile water control 2.
• Hydrogen peroxide solution can also be used for manual bladder irrigation to evacuate bladder clots, and has been shown to be a simple and effective option for managing bladder clot retention 3.
• Initial management of urinary retention involves assessment of urethral patency with prompt and complete bladder decompression by catheterization 4.

Efficacy of Treatment Options

• The mean time for clot evacuation in an in vitro model was 2.7 minutes for t-PA solution 2 mg/mL versus 7.3 minutes for the control 2.
• Irrigation with t-PA solution 2 mg/mL required less irrigant (180 mL vs. 500 mL) for complete evacuation compared to the control 2.
• Hydrogen peroxide solution was successful in evacuating bladder clots in 27 out of 31 patients in a single-center retrospective study 3.

Causes and Evaluation of Acute Urinary Retention

• Acute urinary retention can be caused by obstructive, infectious, inflammatory, iatrogenic, and neurologic problems 5, 6, 4.
• Initial evaluation should involve a detailed history and a focused physical examination with neurologic evaluation 4.
• Diagnostic testing should include measurement of postvoid residual (PVR) volume of urine 4.