World Journal of Urology
CATCH‑22: a manual bladder washout protocol to improve care for clot
· Shannon McGrath
· Daniel Christidis
· Nathan Lawrentschuk
Received: 31 January 2018 / Accepted: 17 May 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
Purpose To review current practices in manual bladder washouts (MBW) for haematuria with clot retention, comparing
those conducted by a urology unit to other inpatient services. Secondly, to describe a standardised protocol for MBWs.
Methods Prospective data were collected for patients treated for clot retention, from initial management by referral units
through to implementation of a standardised MBW by the urology service. Outcomes measured included re-catheterisation,
MBW volumes, clot evacuated and time to discharge or subsequent intervention.
Results Initial catheters inserted by referral teams were sized 16 Fr–20 Fr, all except one requiring upsizing. Mean washout
volumes of 145 ml (SD 125) and 5392 ml (SD 847) were used by referring units and the urology service, respectively. Mean
volume of clot evacuated by the standardised MBW was 617 ml (SD 313). Continuous bladder irrigation (CBI) was com-
menced in 16 patients (66%) prior to referral to urology. Median time to discharge was 48 h.
Conclusion Initial catheter insertion is of inadequate size, as is the volume of washout performed. Referring services fail to
clear adequate amounts of clot with washouts posing potential risks to patients. The standard management of clot retention
should involve the use of at least a 22 F catheter, implement best practice infection control and adopt the last Clot + 1L rule
with catheter manipulation. The key points of our recommended MBW are summarised with the acronym CATCH-22. This
protocol can guide initial management of clot retention and be used as an educational tool.
Keywords Haematuria · Clot retention · Manual bladder washout · Continuous bladder irrigation
Clot retention is a common urological condition. While it
is considered a urological emergency, its underlying patho-
physiology and subsequent management with a manual
bladder washout (MBW) is poorly understood . Incorrect,
inadequate or untimely management may result in signiﬁ-
cant morbidity and likely to increase costs to patients and
healthcare systems. Currently, there are no clear guidelines
to assist with timely and eﬀective MBWs for patients with
This study reviews local practices and literature regarding
MBWs, comparing urology services to other inpatient units.
Secondly, we describe and recommend a simple and repro-
ducible protocol for MBWs providing a standardised man-
agement plan for clot retention.
* Emma Clarebrough
Department of Surgery, Royal Melbourne Hospital,
Melbourne, VIC, Australia
Young Urology Researchers Organisation (YURO),
Department of Surgery, Austin Health, University
of Melbourne, Melbourne, VIC, Australia
Department of Surgery, University of Melbourne, Austin
Health, Melbourne, Australia
Olivia Newton John Cancer Research Institute, Austin
Health, Melbourne, Australia
Division of Cancer Surgery, Peter MacCallum Cancer
Centre, Melbourne, Australia