Continuous Bladder Irrigation (CBI)

Continuous bladder irrigation is a procedure that flushes the bladder with sterile saline via a three-way Foley catheter to prevent or dissolve blood clots - most commonly after transurethral resection of the prostate (TURP) or other bladder/prostatic surgery.

Indications

Post-TURP or post-prostatectomy hematuria with clot risk
Gross hematuria with clot retention
Hemorrhagic cystitis (radiation-induced, cyclophosphamide-related)
Post-bladder tumor resection

Equipment Needed

Three-way (triple-lumen) Foley catheter - 22F to 26F (larger bore accommodates clot passage)
- Port 1: irrigation inflow
- Port 2: drainage outflow
- Port 3: balloon inflation
Sterile normal saline in 2-L or 4-L bags
IV administration/irrigation tubing set
Large-volume drainage collection bag
IV pole

Step-by-Step Procedure

The 10-step photo guide below comes from Roberts and Hedges' Clinical Procedures in Emergency Medicine:

CBI 10-step procedure - Roberts & Hedges

Steps 1-7: Catheter insertion (if not already in place)

Prepare equipment; place a sterile fenestrated drape. Retract foreskin if uncircumcised.
Hold the penis with the non-dominant hand; cleanse the meatus and surrounding tissue with antiseptic (hand is now contaminated - do not release grip).
Inject 5-10 mL of 2% viscous lidocaine into the urethra for topical anesthesia and urethral distention. Wait 5-10 minutes for maximum effect.
Hold the penis taut and upright; pass the catheter gently into the urethra.
Advance the catheter fully to the hilt before inflating the balloon. If resistance or patient discomfort occurs, deflate immediately and reposition.
After balloon inflation, slowly withdraw the catheter until the balloon seats against the bladder neck. Connect to the drainage system.
Affix the catheter to the thigh with tape or a catheter-specific attachment device.

Steps 8-10: Setting up irrigation

Attach the irrigation port to a 2-4 L bag of sterile saline irrigation fluid hung on an IV pole. Attach the drainage port to a large-volume collection bag at the bedside.
Begin continuous infusion by gravity. Rates of 1 to 2 L/hr are acceptable, provided the volume drained equals the volume infused.
Monitor output closely - adjust the flow rate based on urine color. The goal is clear urinary effluent.

Flow Rate Titration

Urine color	Action
Bright red / frank blood	Increase flow rate; consider manual syringe flush to break up clots
Dark pink/rose	Maintain current rate
Light pink/straw	Can cautiously decrease rate
Clear	Consider stopping CBI if sustained

The rate can be brisk - 1 to 2 L/hr or more - as long as output volume equals input volume. Use 60-mL aliquots with a catheter-tipped syringe for manual irrigation if gravity is insufficient to clear a clot.

Calculating Urine Output During CBI

Because saline is continuously entering the drainage bag, you cannot read urine output directly. Use this formula:

True urine output = Total drainage bag volume - Total irrigation saline infused

Track saline infused carefully on a running worksheet. Document at regular intervals (every 1-4 hours depending on clinical need).

Monitoring and Nursing Care

Check urine color every 15-30 minutes initially; adjust flow accordingly
Ensure the catheter and tubing are free of kinks at all times
If drainage stops suddenly, suspect clot obstruction - perform a manual bladder irrigation with a 60-mL catheter-tipped syringe
Ensure output volume equals input volume; if less is draining than going in, the catheter may be blocked
Monitor for bladder distension - patient reports suprapubic pressure, urge to void around the catheter, or leakage around the catheter

Complications to Watch For

Complication	Signs	Action
Catheter obstruction by clot	Reduced/absent drainage, suprapubic pain	Manual flush with 60-mL syringe
Bladder distension	Suprapubic fullness, leakage around catheter	Check tubing for kinks; manual flush
Fluid overload (over-irrigation)	Edema, electrolyte imbalance	Ensure in = out; slow rate
Infection (CAUTI)	Fever, foul-smelling urine	Routine antibiotic prophylaxis is NOT recommended; treat if symptomatic
Bladder spasm	Cramping, urge around catheter	Antispasmodics (e.g., oxybutynin) may help

Routine antimicrobial prophylaxis should not be used during catheterization to avoid promoting antimicrobial resistance. - Roberts and Hedges' Clinical Procedures in Emergency Medicine

When to Stop CBI

Urine remains consistently clear for several hours
Physician orders discontinuation based on clinical assessment
Typically 12-24 hours post-operatively after TURP, though this varies by case

Key Points Summary

Always use a three-way (22-26F) Foley - a standard two-way catheter cannot handle simultaneous inflow and outflow
Gravity drive at 1-2 L/hr is sufficient; titrate to urine color
Always verify drainage = infusion to avoid bladder over-distension
Calculate true urine output by subtracting total irrigant infused from total drainage
A manual syringe flush with 60 mL saline is the first response to catheter obstruction
Roberts and Hedges' Clinical Procedures in Emergency Medicine, Fig. 55.21 and Bladder Irrigation section
Bailey and Love's Short Practice of Surgery 28th Ed., Urology chapter (post-TURP CBI context)

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