What is the management for a patient with a suprapubic (urinary catheter inserted through the abdomen) catheter presenting with hematuria (blood in urine)?

Management of Hematuria with a Suprapubic Catheter

For patients with a suprapubic catheter presenting with hematuria, initial management should include catheter irrigation with sterile saline to clear blood clots, followed by evaluation for underlying causes including urinary tract infection, catheter-related trauma, or bladder pathology. 1, 2

Initial Assessment and Management

Immediate Actions

• Assess hemodynamic stability - vital signs including blood pressure and heart rate
• Evaluate the severity of bleeding - mild post-insertion bleeding usually resolves spontaneously 2
• Perform catheter irrigation:
  • Use a large syringe (≥10 mL) through the drainage port for superior flow rates (approximately 30 mL/s) 2
  • Irrigate with sterile 0.9% sodium chloride to clear blood clots and restore drainage 2

Diagnostic Workup

1. Urinalysis and urine culture - to identify infection as a potential cause 2
2. Assess catheter position and patency - ensure proper placement and rule out catheter malposition 3, 4
3. Consider imaging if bleeding is significant or persistent:
   • Ultrasound of bladder and kidneys
   • CT scan if more serious pathology is suspected

Management Based on Etiology

Catheter-Related Causes

1. Catheter irritation/trauma:

   • Consider replacing with a smaller catheter size (typically 12-14 Fr for adults) to reduce urethral irritation 2
   • Ensure proper catheter fixation to avoid movement and traction 2

2. Catheter blockage:

   • If blockage is suspected, replace the catheter
   • For recurrent blockages, consider using a larger three-way catheter (22-24 Fr) for better drainage of blood clots 2
   • Consider continuous bladder irrigation for persistent bleeding

3. Catheter malposition:

   • If the catheter is improperly positioned, remove and replace under appropriate guidance 3, 4
   • For difficult cases, consider ultrasound guidance for catheter placement 5

Infectious Causes

1. Urinary tract infection:
   • Obtain urine culture before starting antibiotics 2
   • Initiate empiric antibiotics if signs of systemic infection are present
   • Adjust antibiotics based on culture results and sensitivity 2

Bladder Pathology

1. Bladder spasms:

   • Consider anticholinergic medications (e.g., oxybutynin) or beta-3 agonists (e.g., mirabegron) 2
   • Ensure adequate analgesia with paracetamol or anti-inflammatory medications 2

2. Bladder stones or tumors:

   • If suspected, refer for urological evaluation and appropriate imaging 2
   • May require cystoscopy for definitive diagnosis and treatment

Special Considerations

For Persistent or Severe Bleeding

• If bleeding is significant or persistent, urological consultation is recommended 2
• Consider continuous bladder irrigation with a three-way catheter
• For severe bleeding, may require cystoscopy to identify and treat the source

For Patients with History of Pelvic Radiation or Surgery

• Higher risk of complications including bowel injury during catheter changes 5
• Consider ultrasound guidance for catheter changes in these high-risk patients 5

For Long-Term Catheter Management

• Perform regular catheter changes every 2-4 weeks to prevent incrustations that may cause bleeding 2
• Consider silver alloy-coated catheters to reduce infection risk 2
• Monitor for signs of catheter-related complications including erosion, perforation, or fistula formation 6, 7

Prevention of Recurrence

• Ensure proper catheter care with regular flushing using sterile saline 2
• Maintain adequate hydration to prevent catheter encrustation
• Avoid unnecessary manipulation of the catheter
• Consider prophylactic antibiotics only if recurrent catheter-associated UTIs 1

By following this systematic approach, most cases of hematuria in patients with suprapubic catheters can be effectively managed while minimizing complications and improving patient outcomes.