What is the best initial management for an elderly patient with urinary retention and bleeding after a Transurethral Resection of the Prostate (TURP), should I place a new catheter in the Emergency Department (ED) or consult urology?

Post-TURP Urinary Retention with Bleeding: ED Catheter Placement

Place a large-caliber urethral catheter (20-24 Fr) with continuous bladder irrigation immediately in the ED to manage clot retention and prevent obstruction, then consult urology for further management. 1, 2

Immediate ED Management

Bladder decompression is the priority and should not be delayed while awaiting urology consultation. 3, 4, 5

Catheter Placement Technique

• Use a large-caliber catheter (20-24 Fr) specifically to prevent clot obstruction and allow adequate drainage 1
• Initiate continuous bladder irrigation (CBI) immediately after placement to clear clots and prevent catheter blockage 1
• Smaller catheters will become obstructed by clots and fail to adequately decompress the bladder

Why ED Placement is Appropriate

• Post-TURP bleeding with retention is a mechanical emergency requiring urgent decompression 3, 5
• Delayed bladder drainage can lead to decreased kidney function and long-term detrusor hypocontractility 3
• The initial management of acute urinary retention is bladder drainage by urethral catheterization, regardless of etiology 3, 6

Concurrent Actions in the ED

Assess Anticoagulation Status

• Check coagulation studies (PT/INR, aPTT) if the patient is on anticoagulation 1
• Hold anticoagulation temporarily if safe from a thrombotic standpoint 1
• Patients on anticoagulation have 23% risk of requiring early postoperative blood transfusion when anticoagulation is recommenced 1

Monitor for Complications

• Watch for post-obstructive diuresis, which is a possible complication after bladder decompression 3
• Monitor for worsening hematuria after catheter placement 3

When to Consult Urology

Consult urology urgently (same ED visit) after catheter placement for the following reasons:

Indications for Urgent Urology Involvement

• Bleeding requiring transfusion occurs in approximately 8% of post-TURP cases and may require transurethral fulguration 2
• Urology needs to determine if office cystoscopy is needed to visualize the prostatic fossa and identify bleeding sites, residual prostatic tissue, or bladder perforation 1
• The urologist will decide if repeat surgical intervention is necessary for persistent bleeding 2

Subsequent Urologic Evaluation

• Cystoscopy to evaluate for bleeding sites, residual prostatic tissue, bladder tumors, or evidence of perforation 1
• Consider CT urography if an upper tract source is suspected or if cystoscopy is non-diagnostic 1

Common Pitfalls to Avoid

• Do not use a small-caliber catheter (14-16 Fr) as it will become obstructed by clots 1
• Do not delay catheter placement waiting for urology consultation, as this increases risk of renal impairment 3
• Do not assume bleeding will resolve spontaneously - post-TURP bleeding requiring transfusion occurs in 8% of cases 2
• Do not restart anticoagulation until bleeding subsides and after discussion with urology 1

Expected Timeline

• Full recovery typically occurs within 4-6 weeks of the original TURP procedure 1
• CBI may need to continue for 24-48 hours until hematuria clears
• Urology will determine timing of catheter removal based on resolution of bleeding