What is the best course of action for a resident with persistent hematuria (blood in urine) and a history of catheter use?

Management of Persistent Hematuria in a Catheterized Resident

Remove the catheter as soon as clinically feasible, as this is the single most important intervention to prevent complications and allow proper evaluation of the hematuria. 1

Immediate Assessment and Catheter Management

The catheter itself is likely contributing to the hematuria and must be addressed first:

• Remove the indwelling catheter immediately if there is no ongoing clinical indication (urinary retention, critical illness requiring strict output monitoring, open sacral wounds, or recent urologic surgery). 1
• If the catheter has been in place ≥2 weeks and symptomatic UTI is suspected, replace it before obtaining urine specimens or starting antimicrobials, as this improves clinical outcomes and diagnostic accuracy. 2, 3
• Catheter trauma, urethral irritation, and false passages are common causes of hematuria in catheterized patients and cannot be diagnosed without direct visualization. 1

Diagnostic Evaluation for Persistent Hematuria

Once the catheter is removed (or if removal is not possible), proceed with systematic evaluation:

Rule Out Infection First

• Do NOT obtain urine cultures or treat asymptomatic bacteriuria in catheterized patients – bacteriuria is universal in chronic catheterization and treatment increases antibiotic resistance without benefit. 1, 2, 3
• Only evaluate for UTI if systemic signs are present: fever, rigors, hypotension, delirium, or new-onset confusion with acute change. 3
• If symptomatic UTI is confirmed, treat for 7 days with prompt symptom resolution or 10-14 days for delayed response. 2, 3

Cystoscopy is Mandatory

• Perform cystoscopy in any patient with hematuria and catheter history to evaluate for bladder lesions, urethral strictures, catheter trauma, false passages, stones, or malignancy. 1
• This is particularly critical given the 25-81% rate of squamous cell carcinoma in chronically catheterized populations (especially spinal cord injury patients). 1
• Cystoscopy is more urgent if the patient has risk factors for transitional cell carcinoma: age >50, smoking history, chemical exposure, chronic irritation from long-term catheterization. 1

Upper Tract Imaging

• Obtain CT urogram or renal ultrasound to evaluate for renal masses, stones, hydronephrosis, or upper tract transitional cell carcinoma. 1, 4, 5
• CT urogram is preferred over intravenous urography for detecting small renal masses. 1

Additional Testing

• Urine cytology should be obtained if risk factors for transitional cell carcinoma exist or if cystoscopy shows suspicious findings. 1
• Measure serum creatinine to assess renal function. 1
• If dysmorphic red blood cells, red cell casts, or proteinuria are present, consider nephrologic evaluation for glomerular disease. 1

Common Pitfalls to Avoid

• Never screen for or treat asymptomatic bacteriuria in catheterized patients – this increases resistance and provides no clinical benefit. 1, 2, 3
• Do not assume hematuria is "just from the catheter" without complete evaluation – malignancy must be excluded. 1, 6
• Do not perform routine surveillance cystoscopy in neurogenic bladder patients, as it is a poor screening test; however, investigate any new hematuria thoroughly. 1
• Avoid leaving catheters in place longer than necessary – risk of complications including UTI increases 3-10% per day. 1, 7

Follow-Up Strategy

• If initial workup is negative, follow the patient semi-annually for 3 years as recommended for microscopic hematuria. 4
• Repeat urinalysis 48 hours after catheter removal to confirm persistence of hematuria. 1
• If hematuria resolves after catheter removal and workup is negative, no further evaluation is needed unless hematuria recurs. 1