What is the management for a patient with ongoing hematuria (passage of blood in urine) and clotting after Interstitial Device for Contraception (IDC) removal?

Management of Ongoing Hematuria with Clots After IDC Removal

For a patient with ongoing hematuria and clot passage after IDC removal, immediate management should include manual bladder irrigation with normal saline to evacuate clots, followed by continuous bladder irrigation via a three-way catheter to prevent clot retention and urinary obstruction.

Initial Assessment and Stabilization

Hemodynamic Assessment

• Evaluate vital signs for signs of hemodynamic instability
• Assess the extent of bleeding using established grading systems 1
• Estimate blood volume loss using ATLS classification:
  • Class I: <15% blood volume loss
  • Class II: 15-30% blood volume loss
  • Class III: 30-40% blood volume loss
  • Class IV: >40% blood volume loss 2

Laboratory Evaluation

• Complete blood count to assess hemoglobin level
• Coagulation studies (PT/INR, PTT)
• Serum creatinine to assess renal function 1
• Urinalysis to quantify RBCs and assess for dysmorphic RBCs or casts 1

Management Algorithm

Step 1: Immediate Interventions

• Insert a large-bore urinary catheter (preferably 22-24 Fr three-way Foley catheter)
• Perform manual bladder irrigation with normal saline to evacuate clots 2
• Initiate continuous bladder irrigation (CBI) with normal saline to prevent further clot formation

Step 2: Bleeding Control Measures

• For persistent bleeding:
  • Apply gentle traction on the catheter to tamponade bleeding at the bladder neck
  • Consider tranexamic acid (10-15 mg/kg followed by infusion of 1-5 mg/kg/h) if bleeding persists 1
  • Correct any coagulopathy with appropriate blood products

Step 3: Identify and Address the Cause

• If bleeding persists despite conservative measures, further assessment is needed 1
• Consider cystoscopy to identify the source of bleeding
• Evaluate for potential causes:
  • Trauma from catheterization
  • Urinary tract infection
  • Underlying bladder pathology (stones, tumors)
  • Coagulopathy

Special Considerations

Anticoagulation Management

• If patient is on anticoagulants, consider temporary discontinuation if bleeding is severe 2
• Balance the risk of anticoagulation cessation against thromboembolism risk 2
• Resume anticoagulation once bleeding is controlled

Clot Retention Management

• For significant clot retention causing urinary obstruction:
  • Use a larger bore catheter (24-26 Fr)
  • Perform more aggressive manual irrigation
  • Consider cystoscopy with clot evacuation if manual irrigation fails 2

Persistent Bleeding

• If bleeding persists despite conservative measures:
  • Consider endovascular intervention (selective embolization) for identified bleeding vessels 2
  • Surgical exploration may be necessary for persistent bleeding unresponsive to other measures 2

Monitoring and Follow-up

• Monitor vital signs and hemoglobin levels
• Assess urine output and color regularly
• Continue CBI until urine is clear for 24-48 hours
• Consider follow-up imaging if bleeding persists or recurs

Common Pitfalls and Caveats

• Avoid needle aspiration of hematomas as this may introduce skin flora and lead to infection 1
• Avoid premature removal of the catheter before bleeding has completely resolved
• Do not rely on single hematocrit measurements as an isolated marker for bleeding 1
• Remember that patients with persistent hematuria after negative initial evaluation should be monitored for the development of significant urologic disease 1

Ongoing hematuria with clot passage after IDC removal requires prompt intervention to prevent complications such as urinary obstruction, bladder tamponade, and hemodynamic instability. The management approach should focus on clot evacuation, bleeding control, and identification of the underlying cause.