What is the differential diagnosis for hematuria following a Transurethral Resection of the Prostate (TURP) procedure with a Foley catheter in place?

Differential Diagnosis for Post-TURP Hematuria with Foley Catheter

The differential diagnosis for hematuria following TURP with a Foley catheter in place includes: inadequate hemostasis from prostatic fossa bleeding vessels, catheter-induced urethral trauma, bladder perforation, urinary tract infection, coagulopathy (particularly in anticoagulated patients), and clot retention causing bladder spasm and secondary bleeding. 1

Primary Causes Related to the TURP Procedure

Inadequate Hemostasis from Prostatic Fossa

• Bleeding from incompletely coagulated vessels in the prostatic fossa is the most common cause of post-TURP hematuria, requiring continuous bladder irrigation with a large-caliber catheter (20-24 Fr) and potentially endoscopic fulguration if conservative measures fail. 1
• The severity and timing of bleeding help distinguish between immediate surgical bleeding (within 24 hours) versus delayed bleeding (typically 7-14 days post-procedure when the eschar separates). 1

Bladder Perforation

• Bladder perforation during TURP presents with persistent hematuria, often accompanied by abdominal pain, distension, or inability to adequately drain the bladder despite catheter patency. 2
• Visualization of perivesical fat or extravasation of irrigant during the procedure strongly suggests perforation, particularly near the trigone or lateral bladder walls. 2
• Extraperitoneal perforations may be managed conservatively with prolonged catheter drainage, while intraperitoneal perforations require surgical repair. 2

Catheter-Related Causes

Catheter-Induced Urethral Trauma

• Foley catheter placement itself causes minimal hematuria (typically <4 RBCs per high-power field), so significant hematuria should not be attributed solely to catheterization. 3
• Traumatic catheter insertion, particularly with balloon inflation in the prostatic urethra rather than the bladder, can cause substantial urethral injury and bleeding. 4
• Males demonstrate greater catheter-induced hematuria than females, but this remains clinically insignificant in most cases. 3

Catheter Obstruction and Clot Retention

• Clot retention from inadequate catheter size or poor drainage leads to bladder distension, spasm, and secondary bleeding from the prostatic fossa. 1, 5
• A catheter smaller than 20-22 Fr may be inadequate for evacuating clots in the setting of significant post-TURP bleeding. 1

Infectious Causes

Catheter-Associated Urinary Tract Infection

• UTI is a common cause of catheter-associated hematuria and should be evaluated with urine culture before initiating antibiotics. 6
• Bacteriuria is present in 6-10% of patients undergoing TURP, and untreated infection increases the risk of sepsis and bleeding complications. 7
• Screening for and treating asymptomatic bacteriuria before TURP is recommended, with antimicrobial therapy initiated shortly before the procedure. 7

Coagulopathy and Anticoagulation-Related Bleeding

Anticoagulation Effects

• Patients on warfarin undergoing TURP are at significantly higher risk for bleeding complications upon resuming anticoagulation, even with bridging protocols. 7, 1
• Bridging with low molecular weight heparin (LMWH) should be held 24 hours preoperatively, with resumption delayed 24-48 hours postoperatively if bleeding concerns exist. 1
• Patients on aspirin have modestly increased minor bleeding without significantly increased transfusion requirements, and bleeding is typically manageable conservatively. 7, 1

Disseminated Intravascular Coagulation (DIC)

• In rare cases, particularly with urosepsis from chronic urinary retention, DIC can cause life-threatening hemorrhage after catheter placement due to fragile, hemorrhagic tissue around the prostatic urethra. 8
• This represents a surgical emergency requiring systemic treatment with coagulation factors, antibiotics, and potentially continuous hemodiafiltration. 8

Clinical Approach to Diagnosis

Immediate Assessment

• Evaluate catheter patency first by flushing with sterile saline to rule out clot obstruction, as this is the most readily correctable cause. 6, 1
• Assess the color and consistency of urine drainage: bright red blood suggests active arterial bleeding, while darker blood with clots suggests venous oozing or clot retention. 5
• Check vital signs for hemodynamic instability indicating significant blood loss requiring transfusion or surgical intervention. 1

Determine Timing and Severity

• Immediate postoperative bleeding (within 24 hours) typically represents inadequate hemostasis, while delayed bleeding (7-14 days) suggests eschar separation or infection. 1
• Persistent gross hematuria despite continuous bladder irrigation warrants endoscopic evaluation to identify and fulgurate bleeding vessels. 1

Rule Out Complications

• If difficulty with catheter placement occurred or pelvic trauma is present, obtain retrograde urethrography before further catheter manipulation to rule out urethral injury. 7, 6
• Consider cystography if bladder perforation is suspected based on inability to achieve adequate drainage or signs of peritoneal irritation. 2
• Obtain urine culture if infection is suspected, particularly if the patient is febrile or has foul-smelling urine. 7, 6

Review Anticoagulation Status

• Document all anticoagulant and antiplatelet medications, including timing of last dose and whether bridging protocols were followed. 7, 1
• Consider reversing anticoagulation if bleeding is significant and life-threatening. 1

Common Pitfalls to Avoid

• Do not attribute significant hematuria (>4 RBCs/HPF) to catheter placement alone, as this suggests underlying pathology requiring investigation. 3
• Avoid blind catheter manipulation if urethral injury is suspected, as this can worsen trauma and bleeding. 7
• Do not delay endoscopic intervention if conservative measures (continuous irrigation, catheter traction) fail within 24 hours, as this increases transfusion requirements and morbidity. 1
• Ensure catheter size is adequate (20-24 Fr) for clot evacuation, as undersized catheters lead to obstruction and secondary complications. 1, 2