What is the management for a clot in a Foley (urinary) catheter?

Management of Clot in Foley Catheter

For a clotted Foley catheter, immediately irrigate forcefully with normal saline using a catheter-tip syringe through the drainage port, and if this fails to restore patency, replace the catheter with a large-bore three-way catheter (22-24 Fr) to enable continuous bladder irrigation and clot evacuation. 1

Immediate Management Algorithm

Step 1: Initial Irrigation Attempt

• Perform forceful manual irrigation with normal saline as the first-line intervention to restore catheter patency 1
• Use a catheter-tip syringe with maximal one-handed pressure through the drainage port (not the irrigation port), as this provides superior flow rates (29-30 mL/s vs 8-9 mL/s) 2
• The minimum flush volume should be twice the catheter volume 1

Step 2: Catheter Replacement if Irrigation Fails

• Replace the existing catheter with a 22-24 Fr three-way Foley catheter if initial irrigation does not clear the clot 2
• The Bardex 22-24 Fr three-way catheters demonstrate superior continuous irrigation flow (1.6-1.7 mL/s) compared to other brands and are optimal for managing clot retention 2
• For severe clot retention unresponsive to standard large-bore catheters, consider using a 28-32 Fr fenestrated rectal tube (Rusch red rubber), which has successfully evacuated clots in 100% of cases where standard catheters failed 3

Step 3: Continuous Bladder Irrigation

• Establish continuous bladder irrigation through the three-way catheter using normal saline 1
• Maintain the irrigation bag 80 cm above the catheter level to optimize gravity flow 2
• Continue irrigation until the drainage is clear for 24 hours 3

Alternative Techniques for Refractory Cases

Hydrogen Peroxide Irrigation

• For difficult-to-remove clots, manual bladder irrigation with hydrogen peroxide solution through a 20 Fr three-way Foley catheter with large-diameter side holes achieved successful clot evacuation in 87% of patients (27/31) 4
• This technique improves efficiency of clot dissolution and evacuation 4

When Conservative Measures Fail

• If clots cannot be evacuated with irrigation techniques, endoscopic intervention in the operating room becomes necessary 3
• Consider cystoscopy the following day to confirm complete clot evacuation if hematuria persists 3

Critical Pitfalls to Avoid

Never use fibrinolytic drugs (urokinase, alteplase) for bladder clots - these are indicated only for catheter lumen thrombosis in central venous catheters, not urinary catheters, and carry greater risk of thrombosis when used inappropriately 1

Do not inflate the balloon during difficult catheterization - this can cause urethral injury and worsen clot formation, particularly in the prostatic urethra 5

Avoid using catheters smaller than 22 Fr for clot management - smaller catheters have inadequate drainage capacity for clot evacuation 2

Underlying Cause Assessment

• Obtain urine culture before initiating antibiotics if infection-related hematuria is suspected 6
• Gross hematuria with clots may indicate bladder injury (present in 77-100% of bladder injuries), particularly in the context of recent catheterization or pelvic trauma 6
• Perform retrograde urethrography before further catheterization attempts if there are signs of urethral injury (blood at meatus, difficulty passing catheter, perineal ecchymosis) 6

Duration of Catheterization

• Maintain catheter drainage until hematuria resolves 6
• For uncomplicated cases after clot evacuation, standard duration is 2-3 weeks, though this may be extended with concurrent injuries 1
• Remove the catheter as soon as clinically appropriate to prevent catheter-associated complications 6

Prevention Strategies

• Use the smallest appropriate catheter size (14-16 Fr) for routine catheterization to minimize urethral trauma 7, 6
• Maintain a closed drainage system below bladder level at all times 8
• Minimize disconnections of the catheter-drainage junction 8