What is the management for bleeding post urinary retention?

Management of Bleeding Post Urinary Retention

The management of bleeding post urinary retention should focus on immediate bladder decompression via urethral catheterization with a large-bore catheter, followed by continuous bladder irrigation to evacuate clots and control bleeding. 1

Initial Management

• Insert a large-bore urethral catheter (typically 20-24 Fr) with a three-way system to allow for continuous bladder irrigation 2
• Perform immediate and complete bladder decompression to relieve pressure and reduce bleeding 1
• Use silver alloy-coated urinary catheters when available to reduce urinary tract infection risk 1
• Establish continuous bladder irrigation with normal saline to evacuate clots and maintain catheter patency 2
• For tenacious clots resistant to irrigation, consider using a thoracic catheter technique for clot evacuation 3

Assessment of Bleeding Severity

• Monitor vital signs for signs of hemodynamic instability (hypotension, tachycardia) which suggests uncontrolled ongoing bleeding requiring immediate intervention 2
• Maintain hemoglobin level of at least > 7 g/dl during resuscitation and mean arterial pressure > 65 mmHg while avoiding fluid overload 2
• For severe bleeding with hemodynamic instability despite resuscitation, immediate intervention through angioembolization or surgery is warranted 2
• Obtain complete blood count, coagulation profile, and renal function tests to assess severity and guide management 4

Management Based on Bleeding Severity

For Mild Bleeding:

• Continue bladder irrigation until clear efflux is achieved 1
• Consider administration of hemostatic agents if bleeding persists 2
• Remove catheter as soon as medically possible (ideally within 24-48 hours) to minimize infection risk 1

For Moderate to Severe Bleeding:

• Transfuse blood products if necessary, following a restrictive transfusion strategy (Hb < 7 g/dl) 2
• For patients on anticoagulation or antiplatelet therapy, consider temporary discontinuation after weighing thrombotic risks 2
• If bleeding persists despite conservative measures, consider cystoscopy to identify and treat the bleeding source 2

For Severe Uncontrolled Bleeding:

• Selective angioembolization should be considered in hemodynamically stable patients when experienced interventional radiologists are immediately available 2
• Surgical exploration may be necessary for unstable patients with ongoing bleeding despite resuscitation 2

Special Considerations

Anticoagulation Management:

• For patients on low-dose aspirin for secondary prevention, continue aspirin through the perioperative period 2
• For patients on dual antiplatelet therapy following recent stent placement, cardiology consultation is essential before any modification 2
• For patients on warfarin, ensure INR is less than 1.5 before invasive procedures 2

Post-Procedural Care:

• Monitor for post-obstructive diuresis, which may require fluid replacement 5
• Perform follow-up imaging (CT scan after 48 hours) for patients with deep lacerations or clinical signs of complications (fever, worsening pain, ongoing blood loss) 2
• Consider urological follow-up to address the underlying cause of urinary retention 1

Addressing Underlying Causes

• For BPH-related retention and bleeding, consider alpha-blocker therapy (tamsulosin or alfuzosin) before catheter removal 1
• For constipation-related retention, treat with osmotic laxatives (polyethylene glycol) or stimulant laxatives (bisacodyl) 6
• For patients with urethral stricture, consider urethral dilation, direct visual internal urethrotomy, or urethroplasty based on stricture characteristics 1
• For patients with neurogenic bladder, clean intermittent self-catheterization may be appropriate for long-term management 1, 4

Prevention of Recurrence

• Treat the underlying cause of urinary retention to prevent recurrent episodes 7
• Inform patients about the increased risk of recurrent urinary retention after catheter removal 1
• For patients with BPH-related retention, surgical intervention should be considered if medical management fails 2, 1
• Regular follow-up to assess for complications such as UTI, bladder stones, and renal function deterioration in patients requiring long-term catheterization 1