What is the management for a leaking catheter after a Transurethral Resection of the Prostate (TURP) procedure?

Management of Catheter Leaking After TURP

The first step is to assess catheter patency by flushing with sterile saline to rule out clot obstruction, then verify proper catheter positioning and balloon inflation, as these are the most readily correctable causes of apparent leakage. 1

Initial Assessment Algorithm

1. Verify Mechanical Function

• Flush the catheter with sterile saline (30-60 mL) to confirm patency and rule out clot obstruction, which is the most common and easily correctable cause 1, 2
• Check that the catheter is adequately sized (20-24 Fr) for post-TURP management, as undersized catheters lead to clot obstruction and secondary complications 1, 2
• Confirm the balloon is properly inflated (typically 30 mL for a 3-way catheter) and positioned in the bladder, not in the prostatic fossa 3

2. Distinguish True Leakage from Bleeding

• Evaluate whether "leaking" represents urine bypassing the catheter versus hematuria with clot formation causing overflow 1
• Check vital signs for hemodynamic instability indicating significant blood loss requiring transfusion or surgical intervention 1
• Assess timing: immediate postoperative bleeding (within 24 hours) typically represents inadequate hemostasis, while delayed bleeding (7-14 days) suggests eschar separation or infection 1

Common Causes and Management

Clot Obstruction (Most Common)

• If clots are present, initiate or increase continuous bladder irrigation (CBI) with normal saline through the 3-way catheter 2, 4
• Manually irrigate with 50-60 mL aliquots of sterile saline using a catheter-tip syringe to evacuate clots 1
• If conservative measures fail within 24 hours, proceed directly to endoscopic intervention with fulguration of bleeding vessels 2

Catheter Malposition

• Consider that the catheter balloon may be obstructing the ureteric orifices if the patient develops flank pain, decreased urine output, or anuria, especially when normal trigonal anatomy has been disrupted by the TURP 3
• Deflate the balloon partially (from 30 mL to 10 mL) and reposition the catheter more distally if ureteric obstruction is suspected 3
• Avoid blind catheter manipulation if urethral injury is suspected, as this can worsen trauma and bleeding 1

Bladder Spasm Causing Bypass

• Bladder spasms can force urine around the catheter, mimicking true leakage 4
• Treat with anticholinergic medications (e.g., oxybutynin 5 mg TID or tolterodine 2 mg BID) to reduce spasm-related leakage 4
• Ensure adequate analgesia, as pain exacerbates bladder spasm 5

Inadequate Catheter Size

• Replace with a larger caliber catheter (22-24 Fr) if the current catheter is undersized, as this is essential for adequate clot evacuation 1, 2
• A 3-way catheter is mandatory for continuous bladder irrigation in the post-TURP setting 2, 4

Management of Persistent Bleeding

Conservative Measures

• Maintain continuous bladder irrigation with normal saline at a rate sufficient to keep effluent light pink or clear 2, 4
• Apply gentle catheter traction for 10 minutes to compress the prostatic fossa (prolonged traction beyond 4-6 hours increases pain without additional benefit for prostates <65 g) 5
• Ensure adequate hydration to maintain urine output and prevent clot formation 4

Escalation for Refractory Bleeding

• If bleeding persists despite adequate irrigation and catheter management for 24 hours, proceed to cystoscopy with fulguration of bleeding vessels 2
• Reserve arterial embolization or open prostatic packing for cases refractory to endoscopic intervention 2
• Transfusion rate after modern TURP is approximately 0.4%, significantly lower than historical rates of 7.1% 4

Special Considerations for Anticoagulated Patients

• For patients on warfarin with significant bleeding, hold warfarin and consider reversal with vitamin K or prothrombin complex concentrate 2
• Patients on bridging low molecular weight heparin (LMWH) should have had it held 24 hours preoperatively; do not resume until bleeding has subsided, typically 24-48 hours postoperatively 2
• Patients on aspirin have modestly increased minor bleeding without significantly increased transfusion requirements, and bleeding is typically manageable with conservative measures 2

Critical Pitfalls to Avoid

• Do not delay endoscopic intervention if conservative measures fail within 24 hours, as this increases transfusion requirements and morbidity 1
• Do not assume all periurethral wetness is catheter leakage; rule out urethral injury, particularly if there was difficult catheter placement 1
• Do not overlook bladder perforation if the patient has persistent hematuria with abdominal pain, distension, or inability to adequately drain despite catheter patency 1, 6
• Ensure the catheter balloon is not overinflated in the prostatic fossa, which can cause ongoing bleeding and patient discomfort 3

When to Suspect Complications Requiring Surgical Intervention

• Persistent gross hematuria despite continuous bladder irrigation and catheter traction warrants endoscopic evaluation 1, 2
• Bladder perforation should be suspected if there is persistent hematuria with abdominal pain, distension, or visualization of perivesical fat during the procedure 1, 6
• Extraperitoneal perforations may be managed conservatively with prolonged catheter drainage (7-10 days), while intraperitoneal perforations require surgical repair 6