What is the management for hematuria after a cesarean section (C-section)?

Management of Blood-Tinged Urine After Cesarean Section

For blood-tinged urine after a cesarean section, the urinary catheter should be removed immediately unless ongoing strict assessment of urine output is needed, as early catheter removal reduces the risk of urinary tract infections and promotes earlier mobilization. 1

Evaluation of Blood-Tinged Urine Post C-Section

When blood-tinged urine is observed after a cesarean section, consider the following:

1. Determine the severity and source:

   • Assess whether it's gross hematuria or mild blood-tinged urine
   • Evaluate timing in relation to surgery
   • Check for associated symptoms (pain, decreased urine output)

2. Consider potential causes:

   • Trauma to bladder or urethra during catheterization
   • Bladder injury during cesarean section
   • Post-surgical inflammation
   • Hematoma formation at the bladder flap

Management Algorithm

For Mild Blood-Tinged Urine Without Complications:

• Remove the urinary catheter immediately if not needed for strict urine output monitoring 1
• Encourage early mobilization to promote normal voiding and reduce thromboembolism risk
• Monitor for successful voiding after catheter removal
• Ensure adequate hydration to dilute urine and promote flushing of the urinary tract

For Significant Hematuria or Concerning Symptoms:

• Obtain imaging studies (CT with contrast) to evaluate for hematoma formation or bladder injury 2
• Monitor hemoglobin levels and vital signs for signs of significant blood loss
• Consider urology consultation if hematuria persists or worsens
• Evaluate for potential vesicouterine fistula if hematuria persists (especially if cyclic) 3

Evidence-Based Rationale

The Enhanced Recovery After Surgery (ERAS) society strongly recommends immediate catheter removal after cesarean delivery when strict urine output monitoring is not required. A Cochrane review of 5 randomized controlled trials with 1065 patients showed that prolonged catheterization was associated with:

• Increased time to first voiding
• Higher incidence of discomfort
• Delayed postoperative ambulation
• Prolonged hospital stay 1

A prospective randomized trial comparing immediate vs. 12-hour catheter removal found significantly lower rates of:

• Postoperative bacteriuria
• Dysuria
• Burning on micturition
• Urinary frequency and urgency
• Shorter time to first voiding
• Earlier ambulation
• Shorter hospital stay 1

Special Considerations

1. Bladder injury risk assessment: Blood-tinged urine may indicate bladder injury during cesarean section, especially if gross hematuria is present. This occurs in approximately 0.1-0.5% of cesarean deliveries.

2. Hematoma evaluation: Hematomas >5 cm at the bladder flap should raise suspicion for uterine dehiscence and require careful evaluation 2

3. Optimal timing for catheter removal: While immediate removal is generally recommended, a 2020 study suggests that removal after 6 hours may be optimal, balancing the risk of urinary retention (higher with immediate removal at 13.6%) against UTI risk (higher with 24-hour removal at 13.4%) 4

Common Pitfalls to Avoid

1. Leaving the catheter in place too long: This increases UTI risk and delays mobilization

2. Ignoring persistent hematuria: May indicate serious complications like vesicouterine fistula or bladder injury 5, 3

3. Underestimating blood loss: Direct measurement by weighing blood-soaked pads is recommended 2

4. Delaying imaging in symptomatic patients: Early detection of complications improves outcomes 2

By following this evidence-based approach, you can appropriately manage blood-tinged urine after cesarean section while minimizing complications and promoting recovery.