Management of Urinary Retention and Bleeding 2 Weeks Post-TURP
In the Emergency Department, immediately place a large-caliber urethral catheter (20-24 Fr) with continuous bladder irrigation as first-line management for post-TURP hematuria and urinary retention at 2 weeks, then consult urology if bleeding does not resolve within hours or if clot retention develops. 1
Initial ED Management Algorithm
Immediate Catheter Placement
- Reinsertion of a large-caliber urethral catheter (20-24 Fr) with continuous bladder irrigation is the first-line intervention for post-TURP hematuria after catheter removal, as this addresses both the urinary retention and the bleeding simultaneously 1
- Hematuria at 2 weeks post-TURP is a recognized complication occurring in more than 5% of patients, typically due to sloughing of necrotic tissue from the resection bed 1
- The urinary retention component may represent either clot retention from the bleeding or detrusor failure, both of which require immediate catheter decompression 2
When to Escalate to Urology Consultation
- If continuous bladder irrigation fails to control bleeding within several hours or if clot retention develops despite irrigation, proceed immediately to urology consultation for endoscopic intervention (cystoscopy with fulguration of bleeding vessels) 1
- Urology consultation is also indicated if the patient cannot tolerate catheter placement or if there is concern for urethral injury during attempted catheterization 1
Critical Assessment Points in the ED
Evaluate Anticoagulation Status
- If the patient is on warfarin, hold the medication and consider reversal if bleeding is significant 1
- For patients on low-molecular-weight heparin (LMWH), ensure it is held and delay resumption by 24-48 hours if ongoing bleeding exists 1
- For patients on novel oral anticoagulants (NOACs), consider specific reversal agents if bleeding is significant 1
- Patients on aspirin typically have only modestly increased minor bleeding that is usually manageable with conservative measures 1
Assess Hemodynamic Stability
- Blood transfusion may be required in approximately 8% of cases with significant post-TURP bleeding 1
- Check hemoglobin/hematocrit to guide transfusion decisions and assess severity of blood loss 1
Why ED Catheter Placement is Appropriate First
Evidence Supporting ED Management
- Post-TURP complications including hematuria and retention are well-recognized and occur in the early postoperative period, with conservative management (catheterization and irrigation) being first-line 1, 3
- The 2-week timeframe places this patient in the typical window for delayed bleeding from tissue sloughing, which responds to catheter drainage and irrigation in the majority of cases 1
- Immediate urology consultation without attempting catheter placement delays definitive bladder decompression and hemorrhage control 1
Surgical Intervention is Reserved for Failure
- Reserve arterial embolization or open prostatic packing only for refractory cases where endoscopic management is insufficient 1
- Surgery is recommended for patients with recurrent gross hematuria refractory to other therapies, but initial conservative management should be attempted first 2
Common Pitfalls to Avoid
- Do not delay catheter placement while waiting for urology consultation - the patient needs immediate bladder decompression and hemorrhage control 1
- Do not prematurely resume anticoagulation - wait at least 24-48 hours after bleeding has subsided before restarting anticoagulation 1
- Do not use small-caliber catheters - a 20-24 Fr catheter is necessary to allow adequate drainage of clots and effective irrigation 1
- Do not discharge the patient after catheter placement without ensuring bleeding is controlled - observe for several hours with continuous irrigation to confirm hemostasis 1