Management of Post Urinary Retention Bleeding
The management of post urinary retention bleeding should focus on bladder decompression through catheterization, followed by continuous bladder irrigation to evacuate blood clots, with consideration of intravesical fibrinolytic agents for persistent clot retention. 1
Initial Assessment and Management
Immediate Interventions
- Insert a large-bore urinary catheter (18-22 Fr) to allow for adequate drainage and clot evacuation
- Perform gentle bladder irrigation with normal saline to evacuate blood clots
- Monitor vital signs and hemoglobin levels to assess bleeding severity
- Maintain adequate hydration to promote urine flow and prevent further clot formation
Catheter Management
- Use a three-way Foley catheter to facilitate continuous bladder irrigation (CBI)
- Ensure catheter is properly secured to prevent movement and urethral trauma 2
- Continue CBI until urine is clear of blood clots for at least 24 hours
Advanced Management for Persistent Bleeding
Pharmacological Interventions
- Consider intravesical fibrinolytic agents (urokinase) for persistent clot retention that doesn't respond to irrigation 3
- Alpha-1 adrenergic receptor antagonists (tamsulosin 0.4mg daily or alfuzosin 10mg daily) should be started at the time of catheter insertion to facilitate subsequent catheter removal and reduce recurrent retention 1
Surgical Interventions
- Cystoscopy with clot evacuation and fulguration of bleeding points may be necessary for persistent bleeding
- For bleeding due to prostatic causes, consider transurethral procedures (TURP, laser therapy) once acute bleeding is controlled 2
Monitoring and Follow-up
Post-Acute Care
- Monitor urine output and color to assess resolution of bleeding
- Measure post-void residual (PVR) volume through bladder scanning or intermittent catheterization once catheter is removed 1
- Consider PVR >100 mL measured consecutively three times as significant retention requiring intervention 1
Catheter Removal Protocol
- Complete at least 3 days of alpha blocker therapy before attempting trial without catheter 1
- Remove catheter when bleeding has resolved and urine is clear
- Perform bladder scan after first void to assess for retention
- If retention recurs, reinsert catheter and consider definitive treatment for underlying cause
Prevention of Recurrence
Medical Management
- Continue alpha blockers for ongoing management of patients with prostatic causes of retention 1
- Consider adding 5-alpha reductase inhibitors (finasteride or dutasteride) for long-term management in men with enlarged prostates (>30cc) 1
- Identify and discontinue medications that can exacerbate urinary retention (anticholinergics, alpha-adrenergic agonists, opioids) 1
Long-term Considerations
- Regular follow-up to evaluate treatment efficacy and adjust therapy as needed
- Monitor for recurrent episodes of retention or bleeding
- Definitive treatment of underlying cause (e.g., TURP for BPH) may be necessary to prevent recurrence 2
Special Considerations
Complications to Watch For
- Catheter-associated urinary tract infections
- Persistent or recurrent bleeding
- Clot retention despite irrigation
- Kidney damage or urosepsis from untreated urinary retention 1
Pitfalls to Avoid
- Inadequate catheter size for effective clot evacuation
- Insufficient irrigation leading to persistent clot formation
- Premature catheter removal before bleeding is controlled
- Failure to identify and treat the underlying cause of retention and bleeding
- Overlooking the need for alpha blocker therapy to facilitate successful catheter removal 1
By following this algorithmic approach, most cases of post urinary retention bleeding can be effectively managed with minimal complications and reduced risk of recurrence.