What is the initial management of hematuria in a male patient who underwent a Transurethral Resection of the Prostate (TURP) procedure?

Post-TURP Hematuria Management in a Small ER Without Urology

In a male patient with hematuria occurring days after TURP, initial management should focus on determining hemodynamic stability, assessing clot retention, and implementing conservative measures including continuous bladder irrigation if needed, with urgent transfer to a facility with urologic capability if bleeding is severe or refractory.

Initial Assessment

Immediate Evaluation

• Check vital signs and hemodynamic status to identify significant blood loss requiring resuscitation 1
• Assess for clot retention by evaluating ability to void, bladder distension on exam, and severity of bleeding 1
• Obtain complete blood count to quantify blood loss and guide transfusion decisions
• Review anticoagulation/antiplatelet medications that may be contributing to bleeding 2

Expected Timeline

Post-TURP hematuria typically resolves within 3 weeks, with 73% of patients having cessation by 2 weeks and 96% by 3 weeks 1. However, clot retention requiring intervention occurs unpredictably and is not correlated with duration of hematuria 1.

Conservative Management (Stable Patients)

If Patient Can Void Without Clots

• Increase oral fluid intake significantly to maintain high urine output and prevent clot formation 1
• Advise strict bed rest and avoidance of straining
• Continue high fluid regimen until urine is completely clear, which may extend beyond the typical 3-week period 1
• Monitor for signs of clot retention: inability to void, suprapubic pain, bladder distension

If Clot Retention Present or Imminent

• Place large-bore three-way Foley catheter (22-24 Fr) to allow clot evacuation
• Initiate continuous bladder irrigation (CBI) with normal saline to prevent clot formation
• Manual irrigation may be needed if clots obstruct the catheter
• Adjust CBI rate to maintain light pink or clear effluent

When to Transfer

Indications for Urgent Urologic Consultation/Transfer

• Hemodynamic instability despite resuscitation 3
• Persistent clot retention despite adequate catheter drainage and irrigation
• Inability to place catheter due to clots or urethral obstruction
• Transfusion requirement exceeding 2 units
• Refractory bleeding continuing beyond 48 hours of conservative management

The AUA guidelines identify gross hematuria due to BPH as an indication for surgical intervention 2, and post-TURP bleeding requiring re-intervention represents a surgical complication that may necessitate repeat endoscopic evaluation or fulguration by a urologist.

Common Pitfalls

• Underestimating blood loss: Visual assessment of hematuria severity is unreliable; serial hemoglobin measurements are essential
• Using small-bore catheters: Inadequate for clot evacuation and will become obstructed
• Premature catheter removal: Should not be attempted until effluent is clear for 24 hours
• Missing clot retention: Can lead to bladder overdistension and permanent detrusor damage
• Failure to recognize need for transfer: Small ERs without urology should have low threshold for transfer when conservative measures fail 2

Risk Factors for Complications

Patients with larger tissue resection volumes and longer operative times have significantly longer bleeding duration (p<0.001 and p<0.05 respectively) 1. However, clot retention occurrence is not predicted by any clinical factors including bleeding duration, making vigilant monitoring essential 1.

Documentation and Disposition

• Document time since TURP, amount of tissue resected if known, and anticoagulation status
• If discharging after stabilization, provide explicit return precautions for clot retention
• Arrange follow-up within 24-48 hours with urology or primary care
• Consider admission for observation if bleeding is moderate or patient reliability is questionable