CME 19/6/14 – Macroscopic Haematuria Management

This is a reminder of things learnt in the practical session run by Stuart Downie on the management of macroscopic haematuria:

• Use a larger catheter (18-20G) to increase the likelihood of successful passage and to minimise pressure/area and hence possible trauma (normal urethra should be able to distend to ~1cm without problem – caution if known stricture)

• All patients with macroscopic haematuria should have a MANUAL BLADDER WAHOUT performed to remove as much clot as possible to assist in the resolution of bleeding and to identify those that require urgent cystoscopy prior to going to the ward.
  • use a 60ml syringe
  • fill this with water or saline for irrigation
  • irrigate the bladder via the main drainage port (spigot the irrigation port if using a 3-way IDC) and then aspirate the fluid introduced
  • the goal is to break up the clot within the bladder so it is aspirated into the syringe and then discarded
  • when there is sufficient clot within the syringe, then discard this fluid and use fresh fluid
  • Stuart advises doing at least 10 irrigation/aspirations in 3 separate areas of the bladder (performed by positioning the IDC at 3 different depths) to ensure
  • if after 10-15mins there is still significant ongoing bleeding and clots – consult urology ?need for urgent cystoscopy further manual washout
  • medical students appear to be particularly good at this procedure, and is a resource worth considering!

• Once nil significant clots evident on MANUAL BLADDER WASHOUT  then proceed to CONTINUOUS BLADDER IRRIGATION via 3-way IDC with normal saline for irrigation (bags positioned ~1m above patients bladder) and patient may be transferred to the ward

Resources:

• Diagnostic Imaging Pathways – Haematuria (Painless Macroscopic)
• Review Article: Management of macroscopic haematuria in the emergency department 2008 EMJ

Here is their proposed guidelines for the management of macroscopic haematuria: