What is the standard treatment for a patient with a Foley catheter presenting with hematuria who is on Eliquis (apixaban) twice daily?

Management of Bright Red, Bloody Urine in a Patient with a Foley Catheter on Eliquis

The standard treatment for a patient with a Foley catheter presenting with bright red, bloody urine while on Eliquis (apixaban) is to remove the Foley catheter as soon as possible and evaluate for underlying urinary tract pathology, as catheter removal alone may resolve hematuria in up to 40% of cases. 1

Initial Management

1. Catheter Management:

   • Remove the Foley catheter within 48 hours of placement if possible 1
   • If the catheter must remain in place:
     • Consider replacing with a silver alloy-coated catheter to reduce infection risk 1
     • Ensure proper catheter care and positioning to minimize trauma

2. Anticoagulation Management:

   • Do not automatically discontinue Eliquis unless bleeding is severe or life-threatening
   • Assess the necessity of continued anticoagulation based on the indication (e.g., atrial fibrillation, VTE)
   • Consider temporary dose reduction rather than complete discontinuation if bleeding is mild to moderate
   • For severe bleeding:
     • Consider reversal with andexanet alfa (a recombinant modified human factor Xa protein) 1
     • Monitor for signs of thrombosis if anticoagulation is reversed or discontinued

Diagnostic Evaluation

Hematuria in anticoagulated patients warrants thorough investigation as studies show 25-30% of patients have significant underlying pathology:

1. Laboratory Assessment:

   • Complete blood count to assess blood loss
   • Renal function tests (BUN/creatinine) to evaluate for acute kidney injury
   • Urinalysis and urine culture to identify infection

2. Imaging and Procedures:

   • Renal ultrasound or CT urography to evaluate upper tract
   • Cystoscopy to evaluate lower urinary tract
   • Do not attribute significant hematuria (>3 RBCs per high-power field) to catheterization alone 2

Underlying Causes to Consider

Studies show that 25% of patients on anticoagulants with gross hematuria have urinary tract tumors 1, 3. Common causes include:

• Urinary tract infection or hemorrhagic cystitis
• Urinary tract malignancy (bladder, kidney)
• Urolithiasis
• Benign prostatic hyperplasia
• Catheter-induced trauma
• Anticoagulant-related nephropathy (rare but serious) 4

Treatment Algorithm

1. For mild hematuria with stable hemodynamics:

   • Remove or replace catheter
   • Increase fluid intake to promote bladder irrigation
   • Continue anticoagulation if clinically necessary
   • Proceed with diagnostic workup

2. For moderate hematuria with clots:

   • Remove or replace catheter with larger bore catheter if needed
   • Consider continuous bladder irrigation
   • Monitor hemoglobin and renal function
   • Consider temporary dose reduction of Eliquis

3. For severe hematuria with hemodynamic instability:

   • Consider anticoagulation reversal
   • Continuous bladder irrigation
   • Possible urologic consultation for cystoscopy with clot evacuation
   • Blood transfusion if necessary
   • ICU monitoring if hemodynamically unstable

Important Considerations

• Catheter-induced hematuria is typically mild and self-limited 2
• Anticoagulation with Eliquis may unmask or exacerbate underlying urologic conditions
• Studies show that even with excessive anticoagulation, 18% of patients were found to have tumors 3
• Foley catheters should be removed as soon as possible as they increase risk of UTI after 48 hours 1

Pitfalls to Avoid

1. Do not assume hematuria is solely due to anticoagulation - multiple studies show significant underlying pathology in 25-30% of anticoagulated patients with hematuria 1, 5, 6

2. Do not leave the catheter in place without evaluation - catheter removal alone may resolve hematuria in many cases 1

3. Do not automatically discontinue anticoagulation - this may increase thrombotic risk; instead, balance bleeding vs. thrombotic risk

4. Do not delay urologic evaluation - early diagnosis of underlying conditions is essential for proper management