What is the management for gross hematuria (visible blood in urine) in a patient with a suprapubic catheter?

Management of Gross Hematuria in a Patient with a Suprapubic Catheter

In a patient with gross hematuria and a suprapubic catheter, immediately assess for bladder trauma (especially if there is history of pelvic fracture or recent trauma), evaluate for infection, ensure adequate catheter drainage to prevent clot obstruction, and perform retrograde cystography if trauma is suspected. 1

Immediate Assessment Steps

Rule Out Bladder Trauma First

• Gross hematuria combined with pelvic fracture indicates bladder injury in 29% of cases and requires immediate imaging. 2
• Perform retrograde cystography (plain film or CT) in stable patients with gross hematuria if there is any mechanism concerning for bladder injury or pelvic ring fracture. 1
• Look for clinical indicators of bladder rupture: inability to void, low urine output, elevated BUN/creatinine (from peritoneal urine absorption), abdominal distention, suprapubic pain, or free intraperitoneal fluid on imaging. 1, 2
• Critical pitfall: Never perform cystography by simply clamping the catheter and allowing IV contrast to accumulate—this inadequate technique misses bladder injuries. 1, 2 Proper cystography requires retrograde gravity filling with minimum 300 mL contrast until maximal bladder distention. 1

Evaluate for Infection

• Catheter-associated urinary tract infection is a common cause of hematuria in catheterized patients. 2
• Obtain urine culture before initiating antibiotics if infection is suspected. 2
• Catheter-associated UTI is the fourth leading cause of hospital-acquired infections and significantly increases morbidity. 2

Assess Catheter Function and Patency

• Replace the suprapubic catheter with an appropriately sized one if drainage is inadequate or if the current catheter is suspected to be causing trauma. 2
• Ensure the catheter is not obstructed by blood clots, as obstruction can worsen bleeding and cause bladder distention. 2
• Maintain continuous bladder drainage to prevent clot retention and bladder overdistention. 1

Management Based on Underlying Cause

If Bladder Trauma is Identified

• Intraperitoneal bladder rupture requires immediate surgical exploration and primary repair—these are typically large "blow-out" injuries that will not heal with catheter drainage alone and risk peritonitis and sepsis. 1
• Uncomplicated extraperitoneal bladder injuries can be managed conservatively with urinary drainage via the existing suprapubic catheter for 2-3 weeks, with expectation of healing in >85% of cases within 10 days. 1
• Complex extraperitoneal ruptures (bladder neck injuries, lesions associated with pelvic fracture requiring fixation, or vaginal/rectal injuries) require surgical exploration and repair. 1

If Infection is Present

• Treat symptomatic catheter-associated UTI with appropriate systemic antibiotics based on culture results. 3
• Consider replacing the suprapubic catheter, as biofilm on the existing catheter harbors bacteria. 3
• Do not treat asymptomatic bacteriuria in catheterized patients—this leads to resistant organisms including Candida without preventing complications. 3

If No Trauma or Infection

• Assess for coagulopathy or anticoagulation therapy, though hematuria should not be attributed solely to anticoagulation without ruling out structural causes. 2
• Consider cystoscopy and imaging to evaluate for bladder pathology or other structural causes if hematuria persists despite conservative measures. 2
• Maintain adequate hydration to promote good urine flow and prevent clot formation. 4

When to Seek Specialist Consultation

• Persistent gross hematuria despite conservative measures requires urology consultation. 2
• Suspicion of bladder injury, especially in the context of pelvic trauma, warrants immediate urology or trauma surgery consultation. 2
• Penetrating trauma with pelvic trajectories requires radiological, endoscopic, or surgical evaluation of the bladder. 1

Common Pitfalls to Avoid

• Never delay imaging in patients with pelvic fracture and gross hematuria—29% have bladder rupture requiring immediate diagnosis. 2
• Do not perform inadequate cystography by clamping the catheter and relying on IV contrast accumulation. 1, 2
• Avoid attributing hematuria solely to anticoagulation without thorough evaluation for structural causes. 2
• Do not treat asymptomatic bacteriuria in long-term catheterized patients, as this promotes resistant organisms. 3
• Remove or replace the suprapubic catheter as soon as clinically appropriate to prevent ongoing complications. 2, 4