Indications to Resume Continuous Bladder Irrigation
Continuous bladder irrigation (CBI) should be resumed when gross hematuria recurs or when there are signs of clot formation that could lead to urinary retention. 1
Primary Indications for Resuming CBI
- Resume CBI immediately when gross hematuria returns after initial resolution, as this is the most common sign suggesting complications such as secondary hemorrhage 2
- Resume CBI when clot formation is observed in the urinary catheter or drainage bag, as clots can lead to urinary retention and increased bleeding 3
- Resume CBI when patients develop symptoms of urinary obstruction (decreased urine output, bladder distension, or discomfort) despite having a catheter in place 1
- Resume CBI when hematocrit values begin to drop after initial stabilization, suggesting recurrent bleeding 4
Risk Factors That Should Lower the Threshold for Resuming CBI
- Patients on anticoagulation or antiplatelet therapy have higher risk of recurrent bleeding and should have CBI resumed at earlier signs of hematuria 2
- Patients who have undergone transurethral resection of prostate (TURP) or bladder (TURB) procedures have increased risk of secondary hemorrhage and may require earlier resumption of CBI 3
- Patients with moderate to severe renal injuries (AAST grade III-V) who develop hematuria should have CBI resumed promptly as secondary hemorrhage occurs in up to 25% of these cases within 2 weeks of injury 2
- Patients with bladder malignancy who develop even minor hematuria after initial resolution should have CBI resumed due to high risk of significant bleeding 5
Monitoring Parameters to Guide CBI Resumption
- Monitor urine color closely - any change from clear to pink or red indicates the need to resume CBI 2
- Monitor vital signs - tachycardia or hypotension may indicate significant blood loss requiring immediate resumption of CBI 1
- Monitor hemoglobin/hematocrit values - a drop may indicate ongoing bleeding even before gross hematuria is visible 4
- Monitor urine output - decreased output may indicate clot formation requiring CBI resumption 3
Duration of Resumed CBI
- Continue CBI until urine is consistently clear for at least 24 hours 1
- For patients with recurrent hematuria after prostate or bladder procedures, CBI should be continued until complete resolution of gross hematuria 3
- For patients with renal trauma, CBI may need to be continued until both gross and microscopic hematuria have resolved 2
- For patients on anticoagulation therapy who develop recurrent bleeding, CBI may need to be continued for a longer period until stable clear urine is achieved 2
Special Considerations
- For intractable hematuria not responding to conventional CBI, consider alternative approaches such as percutaneous nephroureteral tube placement before resorting to more invasive interventions 4
- Local tranexamic acid bladder irrigation may be considered as an adjunct to CBI for persistent hematuria 6
- For patients with severe hematuria due to radiation cystitis or inoperable tumors who fail standard CBI, formalin irrigation may be considered as a last resort 5
- High-pressure irrigation systems may be more effective than traditional gravity-dependent systems for preventing clot formation after urologic procedures 3
Follow-up After CBI Discontinuation
- After resolution of hematuria and discontinuation of CBI, patients should be monitored for at least 48 hours for recurrence before discharge 2
- Patients should be advised to restrict activity until microscopic hematuria has completely resolved 2
- Patients with moderate to severe renal injuries should have follow-up imaging within 48 hours of CBI discontinuation to ensure no ongoing urinary extravasation 2
- Patients should be educated about signs of recurrent bleeding that would necessitate immediate medical attention 7