What is the management for an 89-year-old patient with Benign Prostatic Hyperplasia (BPH) who develops gross hematuria 11 hours after straight catheterization while on Eliquis (apixaban) every 12 hours?

Management of Gross Hematuria Post-Catheterization in an 89-Year-Old BPH Patient on Apixaban

Continue apixaban without interruption and initiate finasteride 5 mg daily for BPH-related prostatic bleeding, as this hematuria is most likely traumatic from catheter passage through an enlarged prostate and does not represent life-threatening hemorrhage requiring anticoagulation reversal. 1, 2

Immediate Assessment

• Confirm hemodynamic stability - Check vital signs, hemoglobin/hematocrit, and assess for signs of significant blood loss 3
• Rule out bladder outlet obstruction from clots - Perform bladder ultrasound to assess for clot retention, as this would require urgent intervention 4
• Verify prostatic source - In an 89-year-old with BPH and recent catheterization, the hematuria is almost certainly traumatic urethral/prostatic mucosal injury from catheter passage through the enlarged prostate 3, 1, 5

Anticoagulation Management

Do NOT discontinue apixaban unless there is active pathological hemorrhage with hemodynamic instability. 6 The FDA label for apixaban clearly states that premature discontinuation increases thrombotic risk, and bleeding should only prompt discontinuation when it is "active pathological hemorrhage." 6

• Traumatic catheter-related hematuria does not constitute an indication to stop apixaban - Studies show that 30% of patients on anticoagulation with hematuria have significant underlying pathology, but catheter trauma in known BPH is an expected, self-limited cause 5, 7
• The short half-life of apixaban (approximately 12 hours) means any bleeding effect will diminish within 24 hours of the last dose without intervention 6
• Reversal agents are NOT indicated - Prothrombin complex concentrates, activated charcoal, or other reversal strategies are reserved for life-threatening bleeding with hemodynamic compromise 6, 3

Medical Therapy for BPH-Related Hematuria

Initiate finasteride 5 mg daily immediately - This is the evidence-based medical treatment for gross hematuria due to BPH and is effective even in patients on anticoagulation. 3, 1, 2, 8

• Finasteride reduces prostatic vascularity and decreases bleeding probability 3, 1
• Efficacy in anticoagulated patients is well-established - 86% of patients on warfarin and 77% on aspirin achieved complete resolution of hematuria with finasteride 8
• Expected time to resolution is 2-12 days for most patients, though larger prostates (>100 gm) may take up to 19-45 days 8
• Long-term success rate is 94% for hematuria grade improvement and 77% for complete resolution 2, 8

Monitoring and Supportive Care

• Maintain adequate hydration to promote urinary flow and prevent clot formation 3
• Avoid repeat catheterization unless absolutely necessary - Each catheterization risks additional mucosal trauma 1
• Monitor hemoglobin at 24-48 hours to ensure stability 3
• Reassess in 2 weeks - Hematuria should resolve within this timeframe on finasteride 2

When to Escalate Care

Consider urological consultation if:

• Hematuria persists beyond 2-4 weeks despite finasteride 2, 8
• Hemodynamic instability develops (hypotension, tachycardia, hemoglobin drop >2 g/dL) 3
• Clot retention causes acute urinary retention requiring continuous bladder irrigation 4
• Patient requires blood transfusion 4

Surgical intervention (TURP) is indicated only for:

• Recurrent gross hematuria refractory to 6-12 months of finasteride therapy 3, 1
• Severe bleeding requiring transfusion or causing clot retention despite medical management 3

Critical Pitfalls to Avoid

• Do not stop apixaban reflexively - The thrombotic risk from discontinuation likely exceeds the bleeding risk from traumatic catheter-related hematuria in this stable patient 6
• Do not use platelet transfusion or desmopressin - There is no evidence supporting these interventions for DOAC-associated bleeding, and platelet transfusion may increase mortality 3
• Do not delay finasteride initiation - Starting finasteride immediately shortens time to hematuria resolution 2, 8
• Do not assume hematuria is solely due to anticoagulation - Up to 30% of anticoagulated patients with hematuria have significant underlying pathology, though in this case the temporal relationship to catheterization makes trauma the obvious cause 5, 7
• Do not perform cystoscopy acutely - This is unnecessary in the setting of known BPH with recent catheterization and risks additional trauma 3, 1

Special Considerations for This 89-Year-Old Patient

• Age increases surgical risk - Medical management with finasteride is strongly preferred over TURP in elderly patients unless absolutely necessary 3
• Prior urinary retention indicates he may benefit from alpha-blocker therapy (e.g., tamsulosin) once hematuria resolves to reduce future retention risk 3
• Renal function should be verified - Apixaban clearance is affected by renal impairment, though dose adjustment is not indicated for bleeding management 3, 6