Hydrogen peroxide bladder irrigation: A simple, safe and effective management option for clot retention

Abstract

While the historical benefits of hydrogen peroxide on wounds and wound healing have recently been questioned, physicians have started to explore its other potential medicinal benefits. We present a case of a 14-year-old girl who presented to our urology unit with macroscopic haematuria and clot retention. Ultrasonography confirmed a large organised intravesical blood clot. Despite numerous attempts, manual bladder irrigation was unsuccessful and caused significant discomfort to the patient. Her clot retention was relieved after 4 irrigation cycles with a 3 % hydrogen peroxide solution. She experienced no complications or side effects post intravesical instillation of hydrogen peroxide.

1. Introduction

Hydrogen peroxide (H₂O₂) was first synthesized in 1818 by Louis Jacques Thénard by reacting nitric acid with barium peroxide.¹ Since then, it has predominantly been used in the field of medicine as an antiseptic solution for the disinfection and irrigation of wounds.² While the historical benefits of H₂O₂ on wounds and wound healing have recently been questioned,² physicians have explored other potential uses of H₂O₂. We describe a novel, minimally invasive technique to facilitate organised clot dissolution using H₂O₂ bladder irrigation.

2. Case presentation

A 14-year-old girl was referred to our urology unit with persistent visible haematuria, symptomatic anaemia and clot retention. On further enquiry, she revealed she was diagnosed with an abdominopelvic malignancy at another tertiary institution 18 months ago. She had initially presented there with a palpable abdominal mass, constipation, and other constitutional symptoms. After radiological imaging identified a pelvic tumour, a core needle biopsy confirmed the diagnosis of embryonal rhabdomyosarcoma (RMS). Neoadjuvant chemotherapy (vincristine, dactinomycin and cyclophosphamide) was commenced, followed by resection of the pelvic mass. Intraoperatively, the tumour mass identified on the right anterolateral pelvic sidewall, abutting the lateral aspect of the bladder and anterior to the broad ligament, was resected. In addition, small nodules seen on the appendix, in the retrocaecal area and pouch of Douglas were also removed. The rest of the abdomen appeared clear of disease. Histology confirmed the presence of embryonal RMS with therapy-induced cytodifferentiation. She had an uncomplicated postoperative course and was discharged to the oncology unit to continue care. On presentation to our urology unit, she was in acute discomfort, tachycardic and pale (Hb 4.8 g/dL) with a noticeable suprapubic fullness to suggest clot retention. Ultrasound of the bladder identified a large, organized clot, measuring 10.7 × 9.7 × 10.8 cm (Fig. 1a). A blood transfusion was commenced, and a three-way irrigation transurethral catheter was inserted. However, repeated attempts of manual irrigation failed to evacuate the clots successfully and was poorly tolerated by the patient. Due to a lack of immediate theatre availability and more life-threatening emergencies amid the first COVID-19 wave, we initiated bladder irrigation with an H₂O₂ solution.

Fig. 1.

Ultrasound of the bladder showing a large organised blood clot involving most of the bladder before initiation of the hydrogen peroxide irrigation (A). Repeat ultrasound after four cycles of hydrogen peroxide showed a significant reduction in the size of the organised clot (B) and eventually rendered the bladder free of clots (C).

A 6 % H₂O₂ solution was diluted to a 3% solution using sterile water. This 3 % solution was then further diluted to a 1:5 ratio using 0.9 % normal saline. Fifty millilitres of this mixture was administered intravesically through a 20 Fr three-way Foley catheter and kept in the bladder for 3 minutes, then aspirated. This cycle was then repeated. The patient only tolerated 4 of these cycles, after which she complained of abdominal discomfort. These cycles, however, proved to have been effective enough. The clots appeared less adherent and more translucent, and manual irrigation became significantly more straightforward. Repeat bladder ultrasound showed a significant reduction in the size of the organised clot (Fig. 1b). The bladder was then wholly evacuated (Fig. 1c), and the patient reported no procedure-related side effects. Continuous bladder irrigation was commenced for the next few days. Once haematuria improved, a cystoscopy ruled out any evidence of a primary tumour or recurrence within the bladder. The patient was then referred to the oncology unit to continue follow-up.

3. Discussion

Intravesical blood clot retention is a urological emergency requiring urgent intervention. Well-known etiologies include urological malignancies and trauma, benign prostatic enlargement, post-operative bleeding post transurethral resection of the prostate and haemorrhagic cystitis.³ The formation of blood clots within the bladder is an essential physiological defense mechanism and an essential part of haemostasis. It occurs when the volume of blood within the bladder exceeds the ability of the urinary urokinase to prevent clot formation. Injured endothelial cells stimulate prothrombin activator that converts prothrombin to thrombin. The latter then converts fibrinogen to fibrin that binds platelets, red blood cells and plasma to form a blood clot.

In most cases, inserting a sizeable urethral catheter and bladder washout with a catheter-tipped syringe followed by irrigation with 0.9 % normal saline is sufficient to evacuate bladder clots and promote further unobstructed bladder drainage. If this fails, patients often need surgery where the clots may be evacuated with a Toomey syringe or Ellick's evacuator. Once the bladder has been cleared of clots, continuous bladder irrigation with 0.9 % normal saline through a three-way catheter should be initiated to prevent further clotting in the immediate postoperative period. While these manoeuvres are highly effective, these methods can fail. Organized clots can be particularly difficult to evacuate because of their large size and because they are not malleable enough to be suctioned using a Toomey syringe or Ellick evacuator.⁴ In some cases, the clot burden may be significant enough to necessitate removal with a resectoscope, which can be both time-consuming and difficult. As a result, some authors have described more novel techniques to assist with bladder clot evacuation.⁵ One such technique is the use of H₂O₂ irrigation.

Kalloo et al. were the first to explore the benefits of H₂O₂ on a stubborn, adherent blood clot. They demonstrated that 3 % H₂O₂ significantly improved gastroscopic visualization in a few animal and human studies by altering the characteristics of the blood clot rendering the clot less adherent, more translucent and easier to remove.^6,7 Wu et al., went on to reaffirm the benefits. Twenty patients with acute upper gastrointestinal bleeding were identified. The suspected site of bleeding was first irrigated with 200 ml of saline. The site was then sprayed with 25–175 ml of 3 % H₂O_2. Images of the visual field were taken before and after irrigation with both saline and H₂O₂. The images were then evaluated by three gastroenterologists and scored using a visual clearance scoring system. The results showed a significant improvement in the mean visual clearance score after irrigation with H₂O₂ compared to irrigation with saline alone (2.13 vs 0.43, P < 0.001). In addition to increased efficacy, this study also reported no clinically significant histological change of the antrum and the duodenal bulb after H₂O₂ therapy, underlying its safety.⁸

The mechanism by which hydrogen peroxide renders the clot less adherent has not yet been fully established. H₂O₂ is believed to inhibit adenosine diphosphate-induced platelet aggregation, thereby modulating thrombus generation.⁵ The powerful oxidizing properties of hydrogen peroxide may also contribute to haemolysis.⁶

Using H₂O₂ for bladder irrigation to facilitate clot dissolution is limited to three papers in the literature. Warlick et al. and Bagheri et al. used low concentration (0.15 %–0.30 %) H₂O₂, in normal saline to successfully dissolve the clots in patients with no complications.^9,10 Similarly, in 2019, Xu et al. released a report of 31 patients treated with hydrogen peroxide for bladder blood clot evacuation. Bladder irrigation fluid was created using a 1:5 mixture of 3 % hydrogen peroxide solution and 0.9 % normal saline. 30–50 mL of irrigation fluid was injected into the bladder through a 20-Fr three-cavity Foley catheter using an irrigation syringe. The fluid was maintained within the bladder for 3–5 minutes, and then the bladder was evacuated. The authors found that the blood clots were easily disrupted and successfully evacuated when the bladder was irrigated with the hydrogen peroxide solution after 6 to 10 cycles of irrigation. Large blood clots became smaller fragments, and the efficiency of manual bladder washout significantly improved over time.¹¹ We used a similar irrigation protocol in our patient, and this technique successfully rendered the bladder free of clots. Fifty millilitres of H₂O₂ irrigation fluid (1:5 mixture of 3 % hydrogen peroxide solution and 0.9 % normal saline) was injected into the bladder and maintained within a maximum of 3 min. Our patient could only tolerate four cycles before she started reporting abdominal discomfort. After four irrigation cycles, the clots appeared less adherent and more translucent and manual irrigation became significantly easier. The bladder was then completely evacuated, and the patient reported no procedure-related side effects.

4. Conclusion

Using H₂O₂ for bladder irrigation may successfully weaken the adhesive properties of bladder blood clots and therefore promote easier bladder clot evacuation. This technique is a simple, effective, non-invasive manoeuvre to deal with the stubborn bladder blood clot that fails to wash out using more well-established manoeuvres.

Ethics approval and consent to participate

Our institution does not require ethics approval for reporting individual case reports.

Consent for publication

Written informed consent was obtained from the patient and mother for the anonymized information and the accompanying images to be published in this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Availability of data and materials

Not applicable.

Level of evidence

5.

Declaration of competing interest

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.