Gross Hematuria
(Bladder Irrigation)
Gross Hematuria
(Bladder Irrigation)
Patients with hematuria requiring bladder irrigation
Manual Irrigation tried in main ED with ongoing clots/blood
Three way foley catheter placed in main ED
Hemodynamically stable
Hb with less than 3 point drop from baseline
If on Anticoagulation, no contraindication to temporarily stopping (e.g mechanical valve)
Significant (greater than 3) drop in Hb.
Anticoagulation that cannot be safely held
Patients requiring placement in a rehab facility, nursing home, or other long-term facilities.
Foley Catheter cannot be placed in ED
H/H Q8hr
Continuous Bladder irrigation
Once "crystal light" pink, stop irrigation and allow to drain normally
If gross hematuria returns restart bladder irrigation
Trial of Tranexamic Acid dwell in bladder (Choi et al, 2023)
Dilute 1000 mg of Tranexamic Acid (10 ml) in 40 m of NS (use a 50 ml Syringe)
Stop Irrigation from above
Clamp Foley below the port
Instill diluted TXA into port so that it fills into the bladder
Allow to dwell for 30 minutes
Release clamp on lower limb of foley system
If urine runs clear, keep lower limb open, upper limb closed
If gross hematuria returns, restart CBI
Urology Consultation
If urology has not been consulted by main ED please do so. This does not need to happen in the middle of the night, can wait until morning.
Medication
Hold anticoagulation if not contraindicated
Hold Antiplatelets medications if no Vascular / Cardiac intervention in the last 12 months
Disposition
Urine clear or light pink tinge
H/H stable over 2 measurements
Follow up for Foley Catheter Management Plan (ok to make this patient's responsibility to arrange)
Ongoing passage of clots and frank blood after 18 hours of treatment in CDU
Evidence of UTI/Sepsis
Ongoing drop in H/H
Per Urology Consultation
Abnormal or unstable vital signs
Learning Links:
Choi H, Kim DW, Jung E, Kye YC, Lee J, Jo S, Kang M, Kim D, Kim B. Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study. Am J Emerg Med. 2023 Jun;68:68-72. doi: 10.1016/j.ajem.2023.03.020. Epub 2023 Mar 16. PMID: 36948083.