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Difficulty: HardUrologic Surgery

A 72-year-old man is evaluated on postoperative day 2 following a transurethral resection of the prostate (TURP) for severe benign prostatic hyperplasia. Continuous bladder irrigation was discontinued 4 hours ago, but his indwelling 3-way urethral catheter was left in place. The patient now complains of sudden-onset, severe lower abdominal pain and an intense, constant urge to void. He appears diaphoretic and uncomfortable. His temperature is 37.1°C (98.8°F), blood pressure is 158/92 mm Hg, pulse is 118/min, and respirations are 18/min. Physical examination reveals a distended, exquisitely tender suprapubic region. The nursing staff reports that no urine has drained into the collection bag over the last 2 hours. Bedside ultrasonography demonstrates a bladder volume of approximately 850 mL with dependent, heterogeneous echogenic material. Which of the following is the most appropriate next step in management?

  1. A
    Computed tomography of the abdomen and pelvis with intravenous contrast
  2. B
    Initiation of broad-spectrum intravenous antibiotics
  3. C
    Immediate return to the operating room for exploratory laparotomy
  4. D
    Comprehensive postoperative fever workup including blood cultures and chest radiography
  5. Manual bladder irrigation with normal saline using a large-bore syringeAnswer

Answer

Manual bladder irrigation with normal saline using a large-bore syringe
This patient has developed acute clot retention, a well-recognized and common complication following transurethral resection of the prostate (TURP). The cessation of continuous bladder irrigation allows residual bleeding to form organized clots, which can physically obstruct the lumen of the indwelling urethral catheter. This leads to acute urinary retention, manifesting as severe suprapubic pain, absent urine output in the collection bag, and sympathetic hyperactivity (tachycardia, diaphoresis, and hypertension). The heterogeneous echogenic material seen on bedside ultrasound represents blood clots. The most appropriate initial step is bedside manual bladder irrigation using a large-bore syringe (such as a Toomey syringe) and sterile normal saline. This forceful flushing and aspiration breaks up and evacuates the clots, restoring catheter patency and rapidly decompressing the bladder. If manual irrigation fails to clear the clots, the next step would be returning to the operating room for cystoscopic clot evacuation.

Step-by-Step Solution

1
Analyze the patient's postoperative timeline and symptoms
The patient is post-TURP with recent cessation of continuous bladder irrigation, presenting with severe suprapubic pain, tachycardia, and absent urine output.
Identifying the clinical context points heavily toward a catheter-related complication rather than a new systemic illness.
2
Interpret the objective findings and bedside imaging
A distended, tender bladder with 850 mL volume and 'heterogeneous echogenic material' on ultrasound confirms acute urinary retention due to blood clots.
Echogenic material in the bladder following a prostate resection represents organizing hematoma/clots that physically obstruct the catheter lumen.
3
Determine the most appropriate immediate intervention
The mechanical obstruction must be cleared manually using a large-bore syringe (e.g., Toomey syringe) and sterile normal saline to flush and aspirate the clots.
Relieving the obstruction decompresses the bladder, immediately resolving the severe pain and sympathetic response (tachycardia/hypertension) without the need for unnecessary imaging or surgery.

Key Concept

Management of Postoperative Clot Retention
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Topics

Urologic Surgery

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