What is the treatment for a blood clot in the bladder?

Treatment of Blood Clots in the Bladder

For blood clots in the bladder, the primary treatment is bladder irrigation with evacuation of the clots, followed by addressing the underlying cause of bleeding. 1

Diagnosis and Initial Assessment

• Key symptoms to identify:

  • Urinary retention
  • Macroscopic hematuria
  • Suprapubic pain or discomfort
  • Inability to void or incomplete emptying

• Diagnostic evaluation:

  • Retrograde cystography (conventional radiography or CT-scan) is the diagnostic procedure of choice if trauma is suspected 1
  • CT scan with IV contrast for hemodynamically stable patients to identify source of bleeding 2
  • Physical examination to assess for abdominal distension, flank mass, and pain 2

Treatment Algorithm

1. Initial Management (Emergent)

• For clot retention causing urinary obstruction:
  • Insert a large-caliber urethral catheter (20-24 Fr) with large-diameter side holes 3
  • Perform manual bladder irrigation with normal saline to evacuate clots 1
  • If clots are difficult to remove through irrigation alone, consider specialized techniques:
    • Hydrogen peroxide solution for manual bladder irrigation 3
    • Intravesical tissue plasminogen activator (tPA) infusions for persistent clots 4
    • Chymotrypsin in sodium bicarbonate solution (40,000 U in 50 mL of 5% sodium bicarbonate) for 30 minutes 5

2. Management Based on Clot Severity and Hemodynamic Status

For Hemodynamically Stable Patients with Manageable Clots:

• Continue bladder irrigation until clear effluent is obtained
• Monitor vital signs and bleeding status for at least 1 hour 2
• Repeat hemoglobin/hematocrit measurements as clinically indicated 2

For Hemodynamically Unstable Patients or Persistent Clots:

• Surgical intervention is required 1
• Options include:
  • Endoscopic clot evacuation and hemostasis
  • Transurethral resection of bleeding source if identified
  • Selective angioembolization for arterial bleeding sources 1

3. Management Based on Underlying Cause

For Traumatic Bladder Injuries:

• Intraperitoneal bladder rupture:

  • Requires surgical exploration and primary repair 1
  • Laparoscopic repair is an option for isolated injuries in hemodynamically stable patients 1

• Extraperitoneal bladder rupture:

  • May be managed non-operatively with urinary drainage via urethral or suprapubic catheter 1
  • Complex extraperitoneal ruptures (bladder neck injuries, pelvic fracture-associated injuries) require surgical exploration and repair 1

For Bladder Tumors:

• Transurethral resection of bladder tumor (TURBT) for control of bleeding 1, 6
• Further management depends on tumor stage and grade 1

For Radiation Cystitis:

• Continuous bladder irrigation
• Consider fulguration of bleeding points if endoscopically accessible 6

Follow-up Care

• Serial physical examinations to assess for expansion of hematoma 2
• Follow-up imaging (CT scan) within 24-72 hours if concerns about hematoma expansion exist 2
• For large hematomas (>5 cm), follow-up CT at 2-4 weeks 2

Special Considerations

• Patients on anticoagulants:

  • Higher risk of significant bleeding and clot formation 6
  • May require temporary discontinuation of anticoagulation if bleeding is severe
  • Balance risk of thromboembolism against risk of continued bleeding

• Pediatric patients:

  • Smaller urethral caliber makes clot evacuation more challenging 7
  • Consider suprapubic catheter placement if urethral catheterization is difficult 1

• Common pitfalls to avoid:

  • Delaying treatment of clot retention, which can lead to bladder distension and potential rupture
  • Failing to identify and treat the underlying cause of bleeding
  • Inadequate clot evacuation leading to recurrent obstruction
  • Overly aggressive manual irrigation causing bladder trauma or perforation

Remember that intravesical clots in active hematuria are considered urological emergencies and must be treated immediately, even during times of pressure on the healthcare system 1.