What are the steps to manage a patient with hematuria (blood in urine) requiring a cath (catheter)?

Management of Hematuria in Patients Requiring Catheterization

In patients with hematuria requiring catheterization, clinicians should perform cystoscopy and upper tract imaging to identify the underlying cause, as catheter trauma alone cannot be assumed to be the source without proper investigation. 1

Initial Assessment and Diagnostic Workup

For All Patients with Hematuria Requiring Catheterization:

1. Obtain urinalysis and urine culture

   • Essential to differentiate between true hematuria, hemoglobinuria, and myoglobinuria 2
   • Evaluate for concurrent urinary tract infection (UTI) which may be the cause or a complication 1
   • Look for pyuria which, when combined with bacteriuria, suggests UTI 1

2. Upper tract imaging

   • CT urography is preferred (92% sensitivity, 93% specificity) 2
   • Alternatives for patients with contrast allergies or renal insufficiency:
     • MR urography
     • Renal ultrasound (less sensitive but specific at 95%) 2

3. Cystoscopy

   • Mandatory for patients with hematuria and indwelling catheters 1
   • Can identify urethral strictures, false passages, bladder lesions, or calculi 1
   • May prompt treatment of strictures or changes in catheterization technique 1

Management Algorithm Based on Findings

If Catheter-Related Trauma is Suspected:

1. Immediate interventions:

   • Remove traumatic catheter
   • Replace with appropriate size catheter (typically smaller)
   • Use proper lubrication and technique
   • Consider visualization with cystoscopy for difficult cases

2. For urethral strictures or false passages:

   • Consider changing catheterization technique 1
   • May require urologic intervention for stricture management

If UTI is Confirmed:

1. Antimicrobial therapy:

   • Based on culture and sensitivity results
   • Treat only symptomatic infections, not asymptomatic bacteriuria 1

2. Catheter management:

   • Remove indwelling catheter as soon as medically and neurologically feasible 1
   • Consider alternatives to indwelling catheters:
     • Intermittent catheterization
     • External catheters
     • Incontinence management devices 1

If Prostatic Bleeding is Identified:

1. Medical management:

   • Consider 5-alpha-reductase inhibitor therapy 2
   • Appropriate antibiotics if bacterial prostatitis is present

2. Surgical intervention:

   • Reserved for recurrent gross hematuria refractory to medical therapy 2

If Malignancy or Other Pathology is Detected:

1. Refer to appropriate specialist:
   • Urology for bladder cancer, upper tract urothelial carcinoma, stones
   • Nephrology for glomerular disease (especially with dysmorphic RBCs, proteinuria, cellular casts) 2

Special Considerations

For Neurogenic Lower Urinary Tract Dysfunction (NLUTD) Patients:

• Higher risk of catheter trauma and complications 1
• May require multichannel urodynamics if experiencing new complications 1
• Avoid treating asymptomatic bacteriuria to prevent antibiotic resistance 1
• Consider changing catheterization technique after cystoscopic evaluation 1

For Patients with Persistent Hematuria:

• Continued surveillance is necessary as malignancies may develop later 2
• Follow-up recommendations:
  • Low-risk patients: Annual urinalysis
  • Intermediate/high-risk patients: Urine cytology and repeat urinalysis at 6,12,24, and 36 months 2

Common Pitfalls to Avoid

1. Assuming catheter trauma is the cause without proper investigation

   • Hematuria may be the first sign of serious underlying pathology 1
   • Failure to investigate can allow significant disease to progress 3

2. Treating asymptomatic bacteriuria

   • Leads to antibiotic resistance without clinical benefit 1
   • Exception: pregnant patients or prior to urologic procedures 1

3. Prolonged use of indwelling catheters

   • Increases risk of UTI, stones, and bladder cancer 1
   • Remove as soon as medically and neurologically stable 1

4. Inadequate follow-up

   • Even with negative initial workup, continued surveillance is necessary 2
   • Risk of malignancy with gross hematuria exceeds 10% 4

By following this structured approach to hematuria in catheterized patients, clinicians can ensure appropriate diagnosis and management while minimizing complications and identifying potentially serious underlying conditions.