Reversal of any coagulopathy:
(1) Keep the platelet count > 50,000 per µL.
(2) Stop any drugs that interfere with platelet function.
(3) Transfuse with fresh frozen plasma (FFP) and/or cryoprecipitate if coagulation factors reduced.
Transfuse blood as needed to maintain an adequate hemoglobin and hematocrit.
Evacuate clots from bladder and control hemorrhage:
(1) Place a large bore Foley catheter and irrigate the bladder to remove blood and blood clots.
(2) Consider cystoscopic evaluation with fulgaration of bleeding sites.
(3) Minimize straining at stool by prevention of constipation.
If bleeding is controlled and no vesicoureteral reflux is seen on cystogram, perform continuous bladder irrigation. If bleeding is severe, consider installation and continuous irrigation of a chemical fulgarating agent. If toxicity develops, water or saline are used to flush the bladder of any residual agent.
Chemical fulgarating agents include:
(1) 0.5% to 1.0% silver nitrate
(2) 1% alum
(3) formalin (1-5% dilution of the 37% aqueous formaldehyde stock solution, buffered)
Silver nitrate or alum are usually tried first, with formalin reserved for more serious or resistant hemorrhages.
