Management of Gross Hematuria from Suprapubic Catheter
For gross hematuria from a suprapubic catheter, immediately assess for bladder perforation or bowel injury with imaging (CT cystography or ultrasound), ensure adequate catheter drainage to prevent clot retention, and replace the catheter if it is malpositioned or causing trauma. 1, 2
Immediate Assessment
Rule out life-threatening complications first:
- Obtain imaging urgently if there is history of pelvic trauma, recent catheter placement/exchange, or signs of peritonitis, as suprapubic catheters can cause bladder perforation or inadvertent bowel injury 1, 3, 4
- Perform CT cystography or ultrasound to evaluate for bladder perforation (85-100% accuracy), which presents with contrast outlining bowel loops in intraperitoneal injuries or contrast confined to pelvis in extraperitoneal injuries 1
- Look for signs of intraperitoneal rupture: inability to void, low urine output, elevated BUN/creatinine, abdominal distention, suprapubic pain, or free fluid on imaging 2
Critical pitfall: Suprapubic catheters in patients with previous pelvic radiation carry higher risk of bowel injury due to tissue changes and adhesions—these cases require ultrasound-guided placement and heightened suspicion for complications 3
Assess Catheter Function and Position
- Verify the catheter is in the bladder and not malpositioned in bowel or other structures, particularly if the catheter was recently placed or exchanged 3, 4
- Ensure adequate drainage to prevent clot retention and bladder overdistention, which can worsen bleeding 1
- Replace the catheter with an appropriately sized one if it appears blocked, malpositioned, or is causing ongoing trauma 2
Evaluate for Infection
- Obtain urine culture before starting antibiotics if infection is suspected, as catheter-associated UTI is a common cause of hematuria and the fourth leading cause of hospital-acquired infections 2
- Look for signs of sepsis (fever, hemodynamic instability), which occurred in 2% of traumatic catheterization cases and requires immediate broad-spectrum antibiotics 5
Assess for Coagulopathy
- Check coagulation studies and platelet count, but do not attribute hematuria solely to anticoagulation without ruling out structural causes—29% of patients with pelvic fracture and gross hematuria have bladder rupture requiring immediate diagnosis 1, 2
Management Based on Findings
If bladder perforation is identified:
- Intraperitoneal perforation requires immediate surgical repair due to risk of peritonitis and sepsis 1
- Uncomplicated extraperitoneal injuries can be managed with catheter drainage for 2-3 weeks, as over 85% heal within 10 days 1
- Complicated extraperitoneal injuries (bladder neck involvement, concurrent rectal/vaginal injury, adjacent orthopedic implants, penetrating injuries) require surgical repair 1
If bowel injury is identified:
- Immediate surgical exploration with resection of necrotic bowel, repair of bladder, and consideration of fecal/urinary diversion is required 3
- Obtain urgent surgical consultation, as bowel perforation from suprapubic catheters carries high mortality from overwhelming sepsis 3
If no structural injury and hematuria persists:
- Maintain continuous bladder drainage to prevent clot retention 1
- Consider continuous bladder irrigation if clots are forming and obstructing drainage 6
- Seek urology consultation for persistent gross hematuria despite conservative measures, as cystoscopy may be needed to evaluate for bladder pathology or ongoing trauma 2
Prevention of Recurrence
- Remove the suprapubic catheter as soon as clinically appropriate to prevent ongoing complications 2
- Use ultrasound guidance for any future suprapubic catheter placement or exchange, especially in high-risk patients (previous pelvic surgery, radiation, or inadequately distended bladder) 3, 7
- Avoid unguided suprapubic catheter changes in patients with previous pelvic radiation or surgery, as tissue changes dramatically increase risk of bowel injury 3