Gross Hematuria with Clot Retention
Unable to void due to blood clots, or significant hematuria
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UrologyEmergency
Gross Hematuria with Clot Retention Management
Gross Hematuria with Clot Retention Management: Gross Hematuria with Clot Retention → Initial Assessment → Hemodynamically Stable? → ⚠️ Resuscitate Firs...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Initial Assessment
Evaluate hemodynamic status and cause
- Vital signs - assess for hypovolemia
- Time since last void
- Anticoagulant/antiplatelet use
- Recent procedures (TURP, biopsy, cystoscopy)
- Known malignancy?
- Trauma history?
- Labs: CBC, BMP, coags, type & screen
03Decision Hemodynamically Stable?
Signs of significant blood loss?
04Warning ⚠️ Resuscitate First
Address hemodynamic instability
- IV access x2, fluid resuscitation
- Type & crossmatch, transfuse if needed
- Hold anticoagulation if possible
- Reverse anticoagulation if life-threatening
- Urology STAT consult
05Action Place Large Bore 3-Way Catheter
≥22 Fr hematuria catheter
- 22-24 Fr 3-way Foley catheter
- Larger lumen for clot passage
- 30mL balloon
- Hematuria catheters have reinforced lumen
- If existing catheter, may need to upsize
06Action Manual Clot Evacuation
MUST do before starting CBI
- Use Toomey syringe (60mL) or Ellik evacuator
- Irrigate with normal saline
- Aspirate clots manually
- Repeat until returns are clear/light pink
- CBI does NOT break up clots - must evacuate first
- May take multiple irrigation cycles
07Decision Clots Successfully Evacuated?
Returns clear or light pink
08Action Initiate Continuous Bladder Irrigation
Prevent new clot formation
- Normal saline irrigation bags (2-4L)
- Connect to inflow port of 3-way catheter
- Large drainage bag on outflow
- Start at rapid rate, then titrate
- Goal: Clear to light pink output
- Typical rate: 1-2 L/hour initially
09Action CBI Monitoring
Continuous assessment
- Monitor urine color every 15-30 min initially
- Adjust rate to maintain light pink
- Check for catheter blockage hourly
- Record true urine output (output - irrigant)
- Watch for bladder distension (blocked catheter)
- Hand irrigate PRN if clots recur
10Warning ⚠️ CBI Precautions
Critical monitoring points
- If inflow >> outflow: STOP - likely blocked
- Risk of bladder rupture if obstructed
- Contraindicated if bladder perforation suspected
- Monitor for hypothermia (cold irrigant)
- Daily labs if ongoing significant bleeding
11Action Evaluate Underlying Cause
Once stable, investigate etiology
- CT urogram (once stable)
- Cystoscopy if not already done
- Common causes: BPH, malignancy, stones, infection
- Post-procedural (TURP, biopsy)
- Anticoagulation-related
- Trauma
12Outcome Hematuria Controlled
Wean CBI when urine clear for 24h
- Gradually decrease CBI rate
- D/C CBI when clear x24h
- Trial of void after catheter removal
- Outpatient follow-up for cause evaluation
13Outcome Requires Intervention
Operative management needed
- TUR of bleeding tumor/vessel
- Embolization for refractory bleeding
- Nephrectomy if upper tract source uncontrolled
- Address malignancy if present
14Action Operative Cystoscopy
Clot evacuation + source control
- Failure of bedside evacuation
- OR for cystoscopy with Ellik evacuator
- Identify bleeding source
- Fulguration of bleeding vessels
- May need TUR of bleeding tumor
- Consider arteriography/embolization if refractory
- Path rejoins step 11Shared downstream outcome
- Path rejoins step 05Shared downstream outcome
Guideline Source
AUA Medical Student Curriculum: Bladder Drainage + Urologic Emergencies
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not address underlying cause workup in detail
- Does not address pediatric gross hematuria
- Does not cover anticoagulation reversal decisions
- CBI rates may vary by institution
- Does not address post-operative hematuria specifics
Contraindicated Populations
bladder_perforationpediatric
Applicable Regions
USEUUKAU
AU: Follow standard practice
EU: EAU guidelines address hematuria management
UK: Similar approach per BAUS guidelines
US: AUA curriculum - 3-way catheter + CBI standard approach
Version 1Next review: 2028-01-11
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Related Resources
Frequently Asked Questions
What is the Gross Hematuria with Clot Retention Management?
The Gross Hematuria with Clot Retention Management is a emergency clinical algorithm for Urology. It provides a structured decision tree to guide clinical decision-making, based on AUA Medical Student Curriculum: Bladder Drainage + Urologic Emergencies.
What guideline is the Gross Hematuria with Clot Retention Management based on?
This algorithm is based on AUA Medical Student Curriculum: Bladder Drainage + Urologic Emergencies (DOI: N/A).
What are the limitations of the Gross Hematuria with Clot Retention Management?
Known limitations include: Does not address underlying cause workup in detail; Does not address pediatric gross hematuria; Does not cover anticoagulation reversal decisions; CBI rates may vary by institution; Does not address post-operative hematuria specifics. Individual patient factors may require deviation from these recommendations.
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