page_title: Hematuria
section_title: Acute clot retention
hierarchical_section_title: Hematuria / Management / Acute clot retention
caption_attribution_description: English: A 60cc/mL Toomey syringe.
context_page_description: Hematuria is defined as the presence of blood or red blood cells in the urine. An anatomical framework is helpful in developing a comprehensive differential diagnosis. Blood or red blood cells can enter and mix with urine at multiple anatomical sites. These include the urinary system, female reproductive system, and integumentary system.
  Urinary causes occur anywhere between the kidney glomerulus and the urethral meatus. These can be divided into glomerular and non-glomerular causes. Non-glomerular causes can be further subdivided into upper urinary tract and lower urinary tract causes.
  After conducting a thorough history and physical examination, further medical testing is warranted. Patients can be stratified into high and low risk. High-risk patients include those with visible hematuria or those with non-visible hematuria and risk factors. A complete evaluation of the urinary tract is indicated for hematuria. This includes imaging of the upper urinary tract and cystoscopy of the lower urinary tract.
context_section_description: Acute clot retention is one of three emergencies that can occur with hematuria. The other two are anemia and shock. Blood clots can prevent urine outflow through either ureter or the bladder. This is known as acute urinary retention. 
  Blood clots that remain in the bladder are digested by urinary urokinase producing fibrin fragments. These fibrin fragments are natural anticoagulants and promote ongoing bleeding from the urinary tract. Removing all blood clots prevents the formation of this natural anticoagulant. This in turns facilitates the cessation of bleeding from the urinary tract.
  The acute management of obstructing clots is the placement of a large (22-24 French) urethral Foley catheter. Clots are evacuated with a Toomey syringe and saline irrigation. If this does not control the bleeding, management should escalate to continuous bladder irrigation (CBI) via a three-port urethral catheter. If both a large urethral Foley catheter and CBI fail, an urgent cystoscopy in the operating room will be necessary. Lastly, a transfusion and/or a correction of a coexisting coagulopathy may be necessary.
caption: A 60cc/mL Toomey syringe.  1) Fill syringe with saline. 2) Connect syringe to a catheter port 3) Instill 180cc of saline 4) Draw back 180cc of bladder urine 5) Dispose of medical waste 6) Repeat until all clots are removed
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