Frank M. Nezu, MD
Mohamed T. Ismail, MD
BASICS
DESCRIPTION
Significant gross hematuria with or without clot retention that occurs following transurethral resection of the prostate (TURP) or transurethral resection of bladder tumor (TURBT)
EPIDEMIOLOGY
• Occurs in up to 11% of patients, typically within the 1st 3 mo after TURP (1)[B]
• TURP is associated with a 2.9% transfusion rate (2)[B]
• 2.2–3.3% of patients require recatheterization, clot evacuation, or return to OR for bleeding after TURP (3)[A]
RISK FACTORS
• Excessive Valsalva/straining/constipation
• Inadequate hemostasis/coagulation of bleeding vessels
• Infection
• Medications: Warfarin, heparin, low molecular weight heaprins, aspirin, thienopyridine (clopidogrel), etc.
• Trauma
• Undermining of bladder neck
Genetics
Patients with deficiencies in the clotting cascade (eg, hemophilia) or other coagulopathies are more prone to hemorrhage.
GENERAL PREVENTION
• Obtain sufficient hemostasis intraoperatively
• Stop anticoagulants or other blood-thinning medications prior to surgery
• Delay starting anticoagulant medications postoperatively if possible, although this practice has been questioned (4)[B]
• Gentle postoperative catheter traction
• 5α-reductase inhibitors, taken pre operatively reduce surgical blood loss intraoperatively (5)[A]
• 5α-reductase inhibitors, do not decrease rates of postoperative clot retention (6)[A]
PATHOPHYSIOLOGY
• Anesthetic technique (regional or general) appears to have no impact on TURP-related bleeding
• Inadequate hemostasis/coagulation of bleeding vessels
• Narcotics may cause constipation and increased intra-abdominal pressure
• NSAIDs are not contraindicated after TURP, they do not increase risk of postoperative adverse events (7)[A]
• Due to the sloughing of necrotic tissue in prostatic fossa or bleeding at the bladder neck
• Size of tissue resected, duration of resection, or presence of prostate cancer does not correlate with the incidence of hematuria post-TURP (1)[B]
• Studies suggest that there is transient change in platelet count, prothrombin time, and fibrinogen and serum sodium concentrations postoperatively, which can be explained on the basis of dilution of the blood
• Prostate cancer is known to trigger disseminated intravascular coagulation (DIC), and this should be kept in mind when performing resection in the face of known advanced prostate cancer
• In the absence of prostate cancer, up to 6% of patients undergoing TURP may develop mild subclinical intravascular coagulopathy
• Urinary fibrinolysis is a normal physiologic process. Plasminogen is converted to plasmin by plasminogen activators
• The presence of a clot in the bladder causes the release of additional plasminogen activators. Evacuation of clot in the bladder is essential to stopping the bleeding
ASSOCIATED CONDITIONS
• BPH
• Bladder cancer
• Prostate cancer
DIAGNOSIS
HISTORY
• Color of urine, presence of clots
• Patient is not able to void (clot retention)
• History of TURP TURBT—timing, complications, catheter removal
• Use of anticoagulation or similar medications
• Excessive straining or trauma; last bowel movement
• History of clotting disorder
• History of prostate cancer
PHYSICAL EXAM
• General: Pallor, dehydrated, acutely ill
• Vitals: Hypotensive or tachycardic
• Abdomen: Bladder distended or palpable
• Genitalia: Edematous; ecchymotic
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• CBC to assess for anemia
• Creatinine level for obstruction
• Urinalysis, urine culture
• Coagulopathy screen (platelets, PT/PTT) particularly if there is suggestion of bleeding from other sites
Imaging
Bladder US or pelvic CT to evaluate for large organized clot within bladder
Diagnostic Procedures/Surgery
Bladder drainage and irrigation with large-caliber hematuria catheter
DIFFERENTIAL DIAGNOSIS
• Bleeding from lower GU tract source: Urethra, prostate, bladder
• Bleeding from upper GU tract source: Ureter, renal pelvis, kidney
TREATMENT
GENERAL MEASURES
• Limit physical activity, encourage bed rest
• Limit Valsalva and avoid constipation through stool softeners
• Adequate hydration; IV fluid resuscitation
• Bladder drainage and clot evaluation with large-caliber hematuria catheter
• Continuous bladder irrigation (CBI) via 3-way Foley catheter to clear clots and prevent new clots from forming in the bladder
• Foley traction, additional inflation of Foley balloon
• Cessation of anticoagulants or blood-thinning medications
• Check CBC and coagulation profile
• PRBC transfusions if necessary, vitamin K and/or FFP if coagulopathic
• CBI with intravesical alum or silver nitrate
• These are reported but rarely necessary:
– Hyperbaric oxygen
– Aminocaproic acid (Amicar) antifibrinolytic
– Hormonal manipulation: LHRH agonists
– Urinary diversion with bilateral PCNs
– Salvage radical prostatectomy
– Selective arterial prostatic embolization (SAPE) (8)[A]
MEDICATION
First Line
• Antibiotics if infected
• Stool softeners
• 5α-reductase inhibitors such as finasteride or dutasteride (although will not have an acute effect)
Second Line
N/A
SURGERY/OTHER PROCEDURES
• Transurethral clot evacuation with fulguration and cauterization (laser or electrocautery) of prostate if bleeding does not subside within a reasonable time frame
– Typical Findings: Visible bleeding arterial vessel or discrete/nondiscrete venous bleeding
• Post-TURBT hemorrhage, more expeditious clot evacuation and fulguration
ONGOING CARE
PROGNOSIS
• The mortality rate for hemorrhage after TURP and TURBT is unknown
• Whether hemorrhage after TURP increases the risk of future prostatic bleeding has not been described in the literature
• Use of stool softeners and avoidance of constipation for several weeks after TURP and TURBT seems advisable
COMPLICATIONS
Severe anemia and/or hypovolemic shock can lead to syncope and/or MI
FOLLOW-UP
Patient Monitoring
• Can be managed on the floor setting with staff who are accustomed to managing catheters and CBI
• Serial CBCs, blood transfusions as necessary
• Monitor coagulation profile, FFP if needed
Patient Resources
N/A
REFERENCES
1. Normand G, Guignet J, Briffaux R, et al. Macroscopic haematuria after transurethral resection of the prostate. Prog Urol. 2006;16(4):461–463.
2. Reich O, Gratzke C, Bachmann A, et al. Morbidity, mortality and early outcome of transurethral resection of the prostate: A prospective multicenter evaluation of 10,654 patients. J Urol. 2008;180(1):246–249.
3. Roehrborn CG. The Agency for the Health Care Policy and Research. Clinical guidelines for the diagnosis and treatment of benign prostatic hyperplasia. Urol Clin North Am. 1995;22(2):445–453.
4. Ehrlich Y, Yossepowitch O, Margel D, et al. Early initiation of aspirin after prostate and transurethral bladder surgeries is not associated with increased incidence of postoperative bleeding: A prospective randomized trial. J Urol.2007;178(2):524–528.
5. Pastore AL, Mariani S, Barrese F, et al. Transurethral resection of prostate and the role of pharmacological treatment with dutasteride in decreasing surgical blood loss. J Endourol. 2013;27(1):68–70.
6. Hahn RG, Fagerström T, Tammela TL, et al. Blood loss and postoperative complications associated with transurethral resection of the prostate after pretreatment with dutasteride. BJU Int. 2007;99:587–594.
7. Kara C, Resorlu B, Cicekbilek I, et al. Analgesic efficacy and safety of nonsteroidal anti-Inflammatory drugs after transurethral resection of prostate. Int Braz J Urol. 2010;36(1):49–54.
8. Rastinehad AR, Caplin DM, Ost MC, et al. Selective arterial prostatic embolization (SAPE) for refractory hematuria of prostatic origin. Urology. 2008;71:181–184.
ADDITIONAL READING
• Kavanagh LE, Jack GS, Lawrentschuk N, et al. Prevention and management of TURP-related hemorrhage. Nat Rev Urol. 2011;8:504–514.
• Mebust WK, Holtgrewe HL, Cockett AT, et al. Transurethral prostatectomy: Immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol.1989;141:243–247.
See Also (Topic, Algorithm, Media)
• Hematuria, Gross and Microscopic, Adult 
• Hemorrhage, Postop, Urologic Considerations
• Hemorrhagic Cystitis
• Urine, Abnormal Color
CODES
ICD9
• 599.71 Gross hematuria
• 998.11 Hemorrhage complicating a procedure
ICD10
• N99.820 Postproc hemor/hemtom of a GU sys org fol a GU sys procedure
• R31.0 Gross hematuria
CLINICAL/SURGICAL PEARLS
• Proper patient selection, identify patients at risk for bleeding with attention to medications.
• Attention to detail at the end of TURP/TURBT, complete hemostasis and evacuation of specimen.
• Avoid constipation postoperatively.
• In patient with clot retention a large-bore catheter is used to evacuate all clots and start continuous bladder irrigation (CBI) immediately.