What is the management for an elderly female patient with gross hematuria after pulling out her Foley (urinary) catheter?

Management of Gross Hematuria After Traumatic Foley Catheter Removal in an Elderly Female

Replace the Foley catheter immediately with an appropriately sized catheter (14-16 Fr) to ensure adequate drainage and prevent clot retention, then assess for urethral or bladder injury. 1

Immediate Catheter Management

• Insert a new Foley catheter promptly to maintain bladder drainage and prevent clot formation that could lead to urinary retention 1
• Use the smallest appropriate catheter size (14-16 Fr) to minimize additional urethral trauma 1
• If there is significant resistance during catheter insertion, blood at the urethral meatus, or inability to pass the catheter easily, stop and obtain retrograde urethrography before proceeding to rule out urethral injury 2, 1
• Ensure the catheter is draining adequately; clot retention is a common complication that may require continuous bladder irrigation if hematuria is severe 3

Assess for Urethral and Bladder Injury

• Examine for blood at the urethral meatus, which indicates potential urethral injury and mandates retrograde urethrography before further catheterization attempts 2, 1
• In elderly females, traumatic catheter removal can cause urethral tears or bladder injury, particularly if there was balloon inflation during removal 1
• If the patient has any history of pelvic trauma, pelvic fractures, or if imaging shows pelvic abnormalities, obtain CT cystography to evaluate for bladder rupture, as gross hematuria with pelvic fracture indicates bladder injury in 29% of cases 2, 1
• Retrograde cystography (plain film or CT) is mandatory in stable patients with gross hematuria and any suspicion of bladder injury 1

Rule Out Infection

• Obtain urine culture before initiating antibiotics if urinary tract infection is suspected, as catheter-associated UTI is a common cause of hematuria and significantly increases morbidity 1
• Catheter-associated UTI is the fourth leading cause of hospital-acquired infections 1
• Do not delay culture collection, as empiric antibiotic therapy will reduce diagnostic yield 4

Monitor for Clot Retention and Hemodynamic Stability

• Assess for signs of clot urinary retention: inability to void (if catheter becomes obstructed), low urine output, suprapubic pain, and abdominal distention 1
• Monitor vital signs closely; hemodynamic instability in the setting of gross hematuria may indicate significant bleeding requiring urgent intervention 5
• If clots are obstructing the catheter, consider continuous bladder irrigation with a three-way catheter to prevent retention 3

Determine Need for Imaging

• CT urography with contrast is indicated if hematuria persists despite catheter replacement and adequate drainage, or if there is concern for upper tract injury 2, 4
• Imaging is required in patients with gross hematuria to evaluate for renal trauma, bladder rupture, or other structural abnormalities 2
• In elderly patients, malignancy must be excluded; gross hematuria carries a 30-40% risk of malignancy and requires urologic evaluation even if self-limited 4

Specialist Consultation

• Seek urology consultation immediately if hematuria persists despite conservative measures, if there is suspicion of urethral or bladder injury, or if the patient becomes hemodynamically unstable 1
• Persistent gross hematuria despite adequate catheter drainage warrants cystoscopy and imaging to evaluate for bladder pathology, urethral injury, or other structural causes 1
• In elderly females with gross hematuria, cystoscopy is mandatory to exclude bladder malignancy, which is the most frequently diagnosed malignancy in hematuria cases 4

Assess for Coagulopathy

• Check complete blood count, platelet count, and coagulation studies (PT/INR, aPTT) to evaluate for bleeding disorders 4
• Review the patient's medication list for anticoagulants or antiplatelet agents; however, do not attribute hematuria solely to these medications—they may unmask underlying pathology that requires investigation 4, 6
• Anticoagulation therapy is not a reason to forgo evaluation of hematuria 4

Catheter Removal and Follow-Up

• Remove the catheter as soon as clinically appropriate (typically within 24-48 hours) to prevent ongoing trauma and reduce infection risk 1
• After catheter removal, monitor for recurrence of hematuria and consider urological evaluation for persistent microscopic hematuria 1
• If hematuria resolves after catheter removal and there are no signs of injury or infection, follow-up urinalysis at 6,12,24, and 36 months is recommended to monitor for recurrence 4

Common Pitfalls to Avoid

• Do not delay catheter replacement in the setting of gross hematuria, as clot retention can lead to bladder distention, further bleeding, and hemodynamic compromise 1, 3
• Do not perform cystography by simply clamping the Foley and allowing IV contrast to accumulate—this inadequate technique misses bladder injuries; proper retrograde filling is required 1
• Do not attribute gross hematuria to age, catheter presence, or anticoagulation alone without thorough evaluation, as malignancy and structural injury must be excluded 4, 6
• Do not attempt repeated catheterization if there is resistance or blood at the meatus—obtain retrograde urethrography first to avoid worsening urethral injury 2, 1