What is the management for a patient with Benign Prostatic Hyperplasia (BPH) on Eliquis (apixaban) who develops gross hematuria after straight catheterization with stable vital signs in a Skilled Nursing Facility (SNF)?

Management of Gross Hematuria Post-Catheterization in BPH Patient on Apixaban

Continue apixaban and initiate finasteride 5 mg daily immediately—traumatic catheter-related hematuria in known BPH does not constitute an indication to stop anticoagulation, and finasteride is the evidence-based medical treatment for gross hematuria due to BPH, effective even in patients on anticoagulation. 1

Immediate Assessment and Monitoring

Confirm hemodynamic stability by checking vital signs, hemoglobin/hematocrit, and assessing for signs of significant blood loss 1. Since the patient has stable vitals, this suggests the bleeding is self-limited and does not require emergent intervention.

• Maintain adequate hydration to promote urinary flow and prevent clot formation 1
• Monitor hemoglobin at 24-48 hours to ensure stability 1
• Assess for clot retention—if the patient develops clot retention with inability to void, this would require more aggressive management 1

Anticoagulation Management

Do not discontinue apixaban. The AUA guidelines specifically state that traumatic catheter-related hematuria does not constitute an indication to stop apixaban, as 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 1.

The FDA label for apixaban notes that it increases bleeding risk, but discontinuation should only occur for "active pathological hemorrhage" 2. Catheter-induced trauma in BPH with stable vitals does not meet this threshold.

Key caveat: If the patient develops hemodynamic instability, requires transfusion, or develops clot retention despite medical management, then apixaban should be held and reversal considered with andexanet alfa (the specific reversal agent for apixaban) 2.

Medical Therapy: Finasteride

Initiate finasteride 5 mg daily immediately. This is the cornerstone of treatment for gross hematuria due to BPH 1, 3, 4.

• Finasteride reduces prostatic vascularity and decreases bleeding probability 1
• In patients actively bleeding, hematuria typically resolves within 2 weeks, with an average time to clear urine of 12 days 3, 4
• Finasteride is effective in 94% of patients with BPH-related hematuria, with 77% experiencing no further bleeding during long-term follow-up 4
• Critically important: Finasteride is effective even in patients on anticoagulation—86% of patients on warfarin and 77% on aspirin had no further bleeding once on finasteride 4

Expected timeline for resolution: The time to resolution correlates with prostate size—smaller prostates (<40g) clear in approximately 2.7 days, while larger prostates (>150g) may take up to 45 days 4. Prior catheterization or TURP history predicts faster resolution (5.5 days vs 18.6 days) 4.

Alpha-Blocker Consideration

Since this patient required straight catheterization (suggesting prior urinary retention or inability to void), consider adding tamsulosin or alfuzosin once hematuria resolves to reduce future retention risk 1, 5. Alpha-blockers should not be started during active hematuria as they do not treat bleeding and may complicate assessment.

Surgical Intervention Criteria

Surgery (TURP) is NOT indicated at this time. Surgical intervention should only be considered for 1, 6:

• Recurrent gross hematuria refractory to 6-12 months of finasteride therapy
• Severe bleeding requiring transfusion
• Clot retention despite medical management
• Hemodynamic instability

Age increases surgical risk, and medical management with finasteride is strongly preferred over TURP in elderly SNF patients unless absolutely necessary 1.

Critical Pitfalls to Avoid

• Do not stop apixaban reflexively—this increases stroke risk without addressing the underlying prostatic bleeding 1, 2
• Do not rush to surgery—medical management with finasteride is highly effective and should be the first-line approach 1, 3, 4
• Do not place an indwelling Foley catheter unless clot retention develops—this increases infection risk and is unnecessary with stable vitals 5
• Ensure other causes of hematuria have been ruled out—while catheter trauma is the likely cause, bladder cancer, stones, and infection should be excluded if hematuria persists beyond expected timeframe 1, 7

Disposition and Follow-Up

The patient can remain in the SNF with close monitoring. Arrange follow-up hemoglobin check at 24-48 hours 1. If hematuria does not begin to improve within 2 weeks on finasteride, or if the patient develops clot retention, hemodynamic instability, or requires transfusion, then transfer to acute care for urologic evaluation 1, 4.