What are the management steps for bleeding associated with a urinary catheter?

Management of Bleeding from a Urinary Catheter

For bleeding from a urinary catheter, immediately apply direct digital pressure at the insertion site for at least 5 minutes, followed by an occlusive dressing, and if bleeding is from within the catheter lumen (hematuria with clots), perform forceful manual irrigation with normal saline as first-line treatment. 1, 2

Initial Assessment

Determine the source and severity of bleeding:

• Bleeding around the insertion site (external): This represents trauma to the urethra or meatus from catheter placement or movement 1, 3
• Bleeding from within the catheter (hematuria with clots): This indicates bladder or urethral injury, or underlying pathology causing gross hematuria 2, 3
• Assess patient's coagulation status (platelet count, INR, aPTT) and anticoagulation medications 1

Management Algorithm by Bleeding Source

External Bleeding (Around Insertion Site)

• Apply direct digital pressure for 5-10 minutes until hemostasis is achieved 1
• Apply sterile occlusive dressing after achieving hemostasis 1
• If bleeding persists despite pressure, place a skin suture at the insertion site 1
• Monitor for hematoma development which may require surgical evacuation if causing local pressure effects 1
• Leave catheter in place if significant bleeding or suspected vessel injury until vascular surgical consultation is obtained 1

Internal Bleeding (Hematuria with Clots)

• Perform forceful manual irrigation with normal saline immediately to restore catheter patency - this is the first-line intervention 2
• Use a minimum flush volume of twice the catheter volume 2
• Establish continuous bladder irrigation through a three-way catheter using normal saline 2
• Maintain catheter drainage until hematuria resolves 2

Critical Pitfall to Avoid

Never use fibrinolytic drugs (urokinase, alteplase, streptokinase) for urinary catheter bleeding or bladder clots - these agents are indicated only for central venous catheter thrombosis, not urinary catheters, and carry greater risk of bleeding complications when used inappropriately 4, 2

Coagulopathy Management

• Routine reversal of coagulopathy is only necessary if:
  • Platelet count < 50 × 10⁹/L, OR
  • aPTT > 1.3 times normal, OR
  • INR > 1.8 1
• For patients on anticoagulants with persistent bleeding, consult interventional radiology or vascular surgery before catheter manipulation 1

Investigation of Underlying Cause

• Obtain urine culture before initiating antibiotics if infection-related hematuria is suspected 2
• Gross hematuria with clots may indicate bladder injury (present in 77-100% of bladder injuries), particularly after recent catheterization or pelvic trauma 2
• Perform retrograde urethrography before further catheterization attempts if signs of urethral injury are present (blood at meatus, difficulty passing catheter, perineal ecchymosis) 2

Duration of Catheterization

• For hematuria with clots: maintain catheter for 2-3 weeks after clot evacuation in uncomplicated cases 2
• Duration may be extended with concurrent injuries 2
• Remove catheter as soon as clinically appropriate to prevent catheter-associated complications 2, 5

When to Consult Urology

• Persistent gross hematuria despite conservative measures 2
• Suspicion of bladder or urethral injury 2
• Recurrent catheter bleeding requiring multiple interventions 3
• Confirm bladder healing with follow-up cystography in complex cases 2

Prevention of Future Bleeding

• Ensure proper catheter placement technique using ultrasound guidance when appropriate to minimize urethral trauma 1
• Maintain catheter patency with regular flushing using 0.9% normal saline 1
• Remove catheters when no longer needed to reduce risk of complications 1, 5
• Patients should be well instructed on catheter care technique and risks 3