Management of Bladder Bleeding in Prostate Cancer Patients
Transcatheter arterial embolization of the vesical or prostatic arteries is the most effective intervention for controlling severe bladder bleeding in prostate cancer patients when conservative measures fail. 1
Initial Management Approaches
- Begin with conservative measures including continuous bladder irrigation through a three-way catheter to evacuate clots and maintain urinary flow 1
- Attempt fulguration (cauterization) of bleeding lesions via cystoscopy if the bleeding source can be identified and accessed 1
- Consider oral tranexamic acid which has been shown to reduce bleeding in prostate surgeries and may help with ongoing hemorrhage 2
Hormonal Management
- Androgen deprivation therapy should be considered as a primary treatment for prostatic bleeding, as it suppresses angiogenesis in the prostate tissue 3
- Finasteride (5α-reductase inhibitor) can be effective in suppressing hematuria caused by prostatic hypervascularity and should be considered early in management 4
Interventional Approaches
- When conservative measures fail and bleeding becomes life-threatening, transcatheter arterial embolization of vesical or prostatic arteries has shown success rates of approximately 90% 1
- The procedure is particularly valuable for elderly patients who may be unfit for surgical intervention 1
- Selective embolization targets only the vessels feeding the bleeding areas, minimizing damage to surrounding tissues 1
Surgical Options
- Transurethral resection of the prostate (TURP) may be considered for persistent bleeding if the patient's condition allows for surgery 4
- For patients with advanced disease and uncontrollable bleeding, cystectomy may be considered but is often not feasible due to the patient's condition 1
Radiation-Induced Bleeding
- For patients with bleeding related to radiation cystitis from previous prostate cancer treatment, special considerations apply 5
- Hyperbaric oxygen therapy may be beneficial in cases where hypovascularity or hypoxemia contribute to chronic radiation-induced cystitis 6
- Referral to urologists experienced in managing post-radiation effects is warranted for long-term and late urinary complications 6
Monitoring and Follow-up
- Regular monitoring of hemoglobin levels and coagulation parameters is essential 2
- Blood transfusion may be necessary when blood loss is rapid and severe 1
- After successful control of bleeding, follow-up cystoscopy may be required to evaluate healing and rule out recurrent disease 6
Important Caveats
- Always rule out other causes of hematuria including bladder cancer, which can coexist with prostate cancer 6
- Consider upper tract imaging to exclude other sources of bleeding 6
- Patients on anticoagulation therapy may require temporary discontinuation or reversal of anticoagulation, balancing the risk of thrombosis against the risk of continued bleeding 1
- The risk of thromboembolic events does not appear to increase with the use of tranexamic acid in prostate surgery patients 2