Clot retention and a DOAC on day 3 after TURP
A 68-year-old man is on day 3 of an inpatient stay after bipolar transurethral resection of a 60 mL prostate. He takes apixaban 5 mg twice daily for atrial fibrillation (CHA2DS2-VASc 4); the last dose was given 36 hours before surgery and was restarted 24 hours postoperatively. He now reports sudden suprapubic pain and inability to void. The catheter has drained little for two hours despite irrigation, and the drainage bag contains dark blood with clots. Blood pressure is 138/82 mmHg, pulse 96, temperature 36.9 °C. Haemoglobin has fallen from 118 g/L to 89 g/L; platelets 210 ×10⁹/L; creatinine 110 µmol/L; INR 1.1; urine culture from admission negative. Saline irrigation through the catheter produces only a trickle of clot-streaked fluid, and the bladder is palpable and tender above the symphysis. The night registrar asks whether to increase the irrigation rate, give tranexamic acid, or take him to theatre.
1. What are your immediate priorities in the next hour, and why?
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The picture is clot retention with continuing prostatic fossa bleeding, not simply a slow catheter. Restoring free drainage is the priority because an over-distended bladder worsens bleeding and pain, and retained clot will not pass through a blocked catheter.
Steps: (1) ABCDE assessment, analgesia, intravenous access, blood for full blood count, coagulation screen, urea and electrolytes, and crossmatch two units. (2) If the catheter is small or blocked, replace it with a 22–24 Fr three-way catheter using an aseptic technique. (3) Perform manual to-and-fro bladder irrigation with 0.9% saline and a bladder syringe until the effluent clears; organised clot requires mechanical evacuation, and a spigot or a faster drip will not move it. (4) Then run continuous bladder irrigation titrated to keep the effluent pale pink. (5) Transfuse if haemoglobin falls below 70 g/L, or below 80 g/L with ischaemic heart disease or ongoing bleeding. (6) Correct coagulopathy after results.
If the bladder cannot be kept clear, or he becomes haemodynamically unstable, proceed to theatre for cystoscopy, clot evacuation, fulguration and, if needed, balloon tamponade of the prostatic fossa. Increasing the irrigation rate alone is inadequate. Systemic tranexamic acid does not dissolve clot and is not a substitute for evacuation; intravesical tranexamic acid is described but should not delay decompression. Avoid traction on the catheter in this setting.
2. How would you manage his apixaban, both reversal now and restarting later?
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Apixaban was restarted 24 hours ago, so there is active drug effect; with creatinine 110 µmol/L the half-life is roughly 12 hours. I would discuss reversal with haematology. Specific reversal with andexanet alfa is reserved for life-threatening bleeding; where it is unavailable, four-factor prothrombin complex concentrate 25–50 U/kg is a reasonable option for major bleeding. Fresh frozen plasma and vitamin K are treatments for warfarin, not for factor Xa inhibitors, and apixaban is not usefully dialysed because it is highly protein bound. Check an anti-Xa level if available, but do not delay control of the bleeding source.
Restarting requires a balance: CHA2DS2-VASc 4 means a meaningful annual stroke risk, so indefinite interruption is unsafe. Once macroscopic haematuria has cleared, no further intervention is planned and haemoglobin is stable, I would usually restart at the full dose after 48–72 hours, with cardiology or haematology input. Direct oral anticoagulants do not require heparin bridging, and bridging in this setting increases bleeding. If bleeding recurs after restarting, the decision is revisited rather than automatically stopping the drug for a long period.
The surgical lesson is that the timing of restart on day 1 was aggressive for a prostate resection bed; a documented plan agreed with cardiology at discharge prevents this dilemma.
3. He is readmitted on day 12 with a further large volume of fresh haematuria and clots, having been discharge-stable. How does this change your thinking?
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Bleeding more than 10–14 days after resection suggests a different mechanism from the expected sloughing of the prostatic fossa: an arterial source such as a pseudoaneurysm of a prostatic branch is the main concern, along with infection, residual adenoma or a coagulation problem.
I would admit him, secure a large three-way catheter, evacuate clot manually, crossmatch and check haemoglobin, clotting and urine culture. The key judgement is not to repeat blind endoscopic fulguration first. Contrast-enhanced CT angiography with selective embolisation of the bleeding vessel is the preferred definitive treatment when a pseudoaneurysm or active extravasation is shown, because it is minimally invasive and avoids further trauma to a healing fossa.
Cystoscopy is still reasonable if the bladder is distended with clot that cannot be evacuated, or if angiography is unavailable and he is unstable; at cystoscopy, look for a discrete arterial jet and use targeted diathermy rather than widespread coagulation. Persistent low-grade oozing with negative angiography may reflect infection or slough and can be managed with irrigation and antibiotics.
After control, review anticoagulation timing again, treat infection, and document the source. Recurrent significant bleeding after TURP warrants imaging rather than repeated blind endoscopic attempts.