What is the management plan for hematuria with clots in a Foley (Foley catheter) in an elderly patient?

From the Guidelines

For an elderly patient with hematuria and clots in their Foley catheter, immediate management should focus on maintaining catheter patency and identifying the underlying cause, with consideration of removing the Foley catheter as soon as possible to avoid increased risk of urinary tract infection, as recommended by 1. To manage the patient, start with manual irrigation of the Foley catheter using a 60mL syringe with sterile normal saline to clear clots. If manual irrigation is unsuccessful, place a three-way Foley catheter (22-24 French) to allow continuous bladder irrigation with normal saline at a rate sufficient to maintain clear or light pink drainage. Some key points to consider in the management plan include:

• Monitoring vital signs, hemoglobin levels, and coagulation parameters, and replacing fluid losses as needed
• Discontinuing anticoagulants or antiplatelet medications if possible
• Obtaining a urinalysis, urine culture, and complete blood count
• Considering IV tranexamic acid 1g every 8 hours for ongoing bleeding
• Urological consultation is essential for further evaluation, which may include cystoscopy to identify and treat the bleeding source, as urinary tract infections, bladder or prostate cancer, radiation cystitis, or trauma from catheterization are common causes in the elderly 1. Once stabilized, a complete workup including renal function tests, CT urogram, or ultrasound may be necessary to determine the underlying etiology. The large-bore catheter helps prevent obstruction from clots, while irrigation dilutes the blood and facilitates clot evacuation, reducing the risk of bladder tamponade and upper urinary tract complications. It is also important to consider the patient's overall health status, including any frailty or comorbidities, when developing the management plan, as these factors can impact the patient's risk for complications and response to treatment 1.

From the Research

Management Plan for Hematuria with Clots in a Foley Catheter

• The management of hematuria with clots in a Foley catheter in an elderly patient involves a comprehensive approach, including resuscitation, ensuring safe and prompt treatment, and follow-up investigations 2.
• Indications for admission include clot retention, cardiovascular instability, uncontrolled pain, sepsis, acute renal failure, coagulopathy, severe comorbidity, heavy hematuria, or social restrictions 2.
• Baseline investigations in the emergency department should include full blood count, urea and electrolyte levels, midstream urine dipstick, beta human chorionic gonadotrophin, and formal microscopy, culture, and sensitivities 2.
• Discharged patients should be advised to drink plenty of clear fluids and return for further medical attention if they experience clot retention, worsening hematuria, uncontrolled pain or fever, or inability to cope at home 2.
• Follow-up by a urological team should be promptly arranged, ideally within the 2-week cancer referral target 2.

Considerations for Elderly Patients

• Elderly patients with hematuria are at a higher risk of urological malignancy, with a positive predictive value of 22.1% in men and 8.3% in women aged >60 years 2.
• The workup for hematuria in elderly patients should consider life-threatening and benign processes, and most workup is driven by a focused history and physical, including laboratory studies and diagnostic imaging 3.

Medication-Related Complications

• Anticoagulant and antiplatelet medications can increase the risk of hematuria-related complications, with enoxaparin associated with the highest rates of hematuria-related events 4.
• Patients on anticoagulant and antiplatelet medications should be closely monitored for signs of hematuria and managed promptly to prevent complications 4.