How to manage a 78-year-old man who pulled out his urinary catheter (UC) and subsequently developed hematuria (blood in urine) with clots, had one irrigation, and now has urinary retention?

Management of Urinary Retention After Catheter Removal with Hematuria and Clots

Immediate bladder catheterization with a new urinary catheter is essential for this 78-year-old man with urinary retention following traumatic catheter removal and hematuria with clots. 1

Initial Management

1. Catheter Insertion

   • Insert a new urinary catheter (16-18 Fr) to decompress the bladder and relieve retention
   • Consider using a 3-way catheter if significant clots remain 1
   • No need for gradual decompression - research shows no benefit of gradual over rapid emptying for urinary retention 2

2. Bladder Irrigation

   • Perform continuous or intermittent bladder irrigation with normal saline until the effluent is clear 1
   • Monitor for clot evacuation and clearing of hematuria
   • Continue irrigation until urine is clear of clots for at least 2 hours

3. Fluid Management

   • Ensure adequate hydration to promote urine flow and prevent clot formation
   • Monitor urine output closely (aim for >0.5 mL/kg/hr)
   • Consider IV fluids if oral intake is inadequate

Assessment for Complications

1. Evaluate for Urethral Trauma

   • Assess for signs of urethral injury (blood at meatus, perineal hematoma)
   • Monitor for persistent hematuria which may indicate more significant injury

2. Monitor Hemodynamic Status

   • Check vital signs, especially for signs of hypovolemia if significant bleeding
   • Monitor hemoglobin/hematocrit if bleeding appears substantial

3. Assess Renal Function

   • Consider checking BUN/creatinine if prolonged retention occurred

Subsequent Management

1. Catheter Care

   • Keep catheter in place for at least 48-72 hours to allow urethral healing 3
   • Secure catheter properly to prevent further trauma
   • Consider prophylactic antibiotics only if high risk for infection (not routinely recommended) 3

2. Trial Without Catheter

   • After hematuria resolves (typically 2-3 days), consider catheter removal
   • Prior to removal, consider starting alpha-blocker therapy (e.g., tamsulosin 0.4 mg daily) to facilitate voiding, especially given patient's age and likely prostatic enlargement 1
   • Perform trial without catheter when hematuria has resolved

3. Post-Catheter Removal Monitoring

   • Measure post-void residual volume after first void
   • Significant retention is defined as PVR >100 mL measured consecutively three times 1
   • If retention recurs, reinsert catheter and consider urological consultation

Indications for Urological Consultation

• Persistent hematuria despite irrigation
• Inability to pass catheter
• Recurrent retention after catheter removal
• Signs of urethral injury requiring surgical intervention
• Suspected bladder perforation

Prevention of Future Episodes

• Consider long-term management options if retention is recurrent:
  • Medical therapy with alpha blockers if BPH is suspected 1
  • Consider 5-alpha reductase inhibitors if prostate is enlarged 1
  • Avoid medications that can worsen retention (anticholinergics, certain antidepressants)
  • Consider intermittent catheterization rather than indwelling catheter if chronic retention is present 3

This approach prioritizes immediate relief of urinary retention while addressing the hematuria and clots, followed by appropriate measures to prevent recurrence and complications.