How do I perform bladder irrigation (bladder wash) on a patient with a Foley catheter who has clot retention or gross hematuria?

How to Perform Bladder Irrigation (Bladder Wash)

For patients with clot retention or gross hematuria, replace the current Foley catheter with a large-bore three-way catheter (22-24 Fr) and perform manual irrigation with normal saline using a catheter-tipped syringe, followed by continuous bladder irrigation if clots persist. 1, 2

Immediate Assessment Before Starting Irrigation

• Verify catheter patency by attempting gentle aspiration—if no urine returns or irrigation fluid won't flow, the catheter is likely obstructed with clots 1, 2
• Assess hematuria severity through visual inspection: light pink urine rarely needs irrigation, while dark red urine with visible clots requires aggressive intervention 1, 2
• Rule out bladder injury if there is history of pelvic trauma, pelvic fracture, difficulty with initial catheter placement, or blood at the urethral meatus—these patients need imaging (retrograde cystography) before irrigation 1, 2
• Check coagulation status and review anticoagulant medications, though hematuria should never be attributed solely to anticoagulation without ruling out structural causes 1

Equipment Setup for Manual Irrigation

• Replace the existing catheter with a large-bore three-way Foley catheter (22-24 Fr minimum) to allow adequate clot evacuation 1, 2
• For severe clot retention unresponsive to standard catheters, consider using a 28-32 Fr fenestrated rectal tube (Rusch red rubber), which has proven superior for evacuating dense clots 3
• Prepare sterile normal saline (room temperature or slightly warmed)—avoid sterile water as it can cause hemolysis 4
• Use a catheter-tipped 60 mL syringe for manual irrigation 4

Manual Irrigation Technique (First-Line Approach)

• Instill 50-60 mL of normal saline through the irrigation port using gentle, steady pressure 4
• Allow the fluid to dwell briefly (10-30 seconds) to help break up clots 4
• Aspirate gently or allow gravity drainage into a collection basin—do not apply excessive suction as this can traumatize bladder mucosa 4
• Repeat this cycle until returning fluid is clear or light pink 4
• Monitor for bladder distention—stop if the patient reports severe pain or if you've instilled more than 300-400 mL without adequate return, as this may indicate bladder perforation 4

Continuous Bladder Irrigation (CBI) Setup

If manual irrigation fails to clear clots or hematuria persists:

• Confirm three-way catheter placement with adequate size (minimum 22 Fr) 5
• Hang 3-liter irrigation bags of normal saline 60-100 cm above the patient's bladder level 5
• Connect irrigation tubing to the irrigation port of the three-way catheter 5
• Adjust flow rate to maintain light pink or clear effluent—typically 200-300 mL/hour initially, increasing to 500-1000 mL/hour for heavy bleeding 5
• Monitor drainage bag continuously—if output decreases despite adequate inflow, the catheter is likely clogged and requires manual irrigation or replacement 5

Advanced Technique for Refractory Clot Retention

For dense clots resistant to standard irrigation:

• Consider tissue plasminogen activator (t-PA) instillation: mix 50 mg Alteplase in 25 mL normal saline, instill into bladder, clamp catheter for 30 minutes, then irrigate—this significantly improves clot evacuation 6
• This technique requires urologist consultation and is reserved for cases where standard irrigation fails 6

Critical Safety Considerations

• Never perform bladder irrigation if urethral injury is suspected (blood at meatus, perineal ecchymosis, inability to pass catheter easily)—obtain retrograde urethrography first 7, 1
• Do not use excessive pressure during manual irrigation—bladder perforation risk increases with forceful instillation, particularly in post-surgical or traumatized bladders 4
• Avoid antiseptic irrigants (chlorhexidine, povidone-iodine, acetic acid) for routine clot evacuation in patients with indwelling catheters—these provide no benefit over normal saline and may increase infection risk 7
• Maintain closed drainage system whenever possible to minimize infection risk 7

When Irrigation Fails

• Obtain urology consultation immediately if clots cannot be evacuated after 30-60 minutes of aggressive manual irrigation 1, 2
• Consider cystoscopy with clot evacuation in the operating room for refractory cases 3
• Maintain catheter drainage until hematuria resolves completely, particularly in post-transurethral procedure patients 1, 2

Post-Irrigation Monitoring

• Continue CBI until effluent remains consistently light pink or clear for 24 hours 2, 5
• Gradually decrease irrigation rate before discontinuing to ensure bleeding has stopped 5
• Remove catheter within 24-48 hours after hematuria resolves to minimize infection risk 2
• Measure post-void residual after catheter removal—if >200 mL, consider intermittent catheterization rather than replacing indwelling catheter 2

Common Pitfalls to Avoid

• Do not perform cystography by simply clamping the Foley and allowing IV contrast to accumulate—this inadequate technique misses bladder injuries 1
• Do not delay imaging in patients with pelvic fracture and gross hematuria, as 29% have bladder rupture requiring immediate diagnosis 1
• Do not attribute persistent hematuria to the catheter itself without investigating underlying causes (infection, trauma, coagulopathy, malignancy) 1, 2