What is the management for a patient with hematuria (blood in urine) after bladder neck contracture?

Management of Hematuria After Bladder Neck Contracture

CT urography is the first-line imaging modality for evaluating hematuria after bladder neck contracture to rule out malignancy and identify the source of bleeding. 1, 2

Initial Assessment and Diagnostic Workup

Immediate Evaluation

• Assess severity of hematuria (microscopic vs. macroscopic)
• Evaluate hemodynamic stability
• Check complete blood count to assess blood loss
• Obtain coagulation profile to rule out bleeding disorders
• Urinalysis with microscopic examination to distinguish true hematuria from hemoglobinuria or myoglobinuria 2

Risk Stratification

Patients with hematuria after bladder neck contracture should be considered high-risk for malignancy due to:

• History of urological procedures
• Potential for missed urothelial carcinoma
• Risk of vascular complications 2, 3

Diagnostic Imaging

First-Line Imaging

• CT urography with delayed phase imaging is the method of choice with 92% sensitivity and 93% specificity for detecting urinary tract malignancies 2, 1
• CT can identify:
  • Residual or recurrent bladder neck contracture
  • Vascular complications (e.g., arteriovesical fistula)
  • Malignancy (bladder cancer, upper tract urothelial carcinoma)
  • Urolithiasis

Alternative Imaging Options

• MR urography for patients with renal insufficiency or contrast allergy 2
• Renal and bladder ultrasound as an initial screening tool if CT is not immediately available 4, 2
• Cystoscopy is essential to directly visualize the bladder neck and identify the source of bleeding 2

Management Algorithm

Conservative Management

1. Bladder irrigation to evacuate clots and maintain urinary drainage
2. Continuous bladder irrigation if active bleeding persists
3. Hemodynamic support with fluid resuscitation and blood transfusion if necessary

Interventional Management

For persistent or severe hematuria:

1. Cystoscopy with fulguration of bleeding vessels at the bladder neck
2. Transurethral resection of the recurrent bladder neck contracture if it's the source of bleeding 5
3. Angiography with embolization if vascular injury or arteriovesical fistula is suspected 6

Surgical Management

For refractory cases:

1. Open surgical exploration if bleeding cannot be controlled endoscopically
2. Open reanastomosis for recurrent bladder neck contracture causing persistent bleeding 5

Follow-up and Surveillance

Short-term Follow-up

• Repeat urinalysis to confirm resolution of hematuria
• Cystoscopy at 4-6 weeks to evaluate healing of the bladder neck

Long-term Surveillance

• Patients with negative evaluations should have urine cytology and repeat urinalysis at 6,12,24, and 36 months 2
• Annual surveillance cystoscopy for at least 3 years due to high risk of recurrent bladder neck contracture and potential for missed malignancy 2, 3

Special Considerations

Vascular Complications

Hematuria after bladder neck procedures may indicate vascular injury, particularly in patients with:

• Massive hematuria after instrumentation
• History of pelvic radiation
• Known vascular disease
• Internal iliac artery aneurysms 6

Malignancy Risk

Persistent hematuria after bladder neck contracture may be a sign of underlying malignancy:

• Urothelial carcinoma can present with hematuria and may have been missed during previous evaluations 3
• Delays in evaluation of gross hematuria can increase cancer-specific mortality by 34% 2

Remember that a single episode of hematuria is equally concerning as recurrent episodes and requires thorough evaluation and continued surveillance 2.