Does a patient need to stop taking Coumadin (warfarin) prior to a cystoscopy?

Warfarin Management for Cystoscopy

For diagnostic cystoscopy, warfarin does not need to be stopped and should be continued, as this is classified as a low-risk bleeding procedure. 1

Risk Classification of Cystoscopy

• Diagnostic cystoscopy with or without mucosal biopsy is classified as a low-risk procedure with bleeding risk less than 1%. 1
• Low-risk endoscopic procedures include diagnostic procedures with mucosal biopsies that do not involve cutting open the mucosa or breaching deep layers. 1

Management Protocol for Diagnostic Cystoscopy

Continue Warfarin Without Interruption

• For low-risk procedures like diagnostic cystoscopy, warfarin therapy should be continued without interruption. 1
• The British Society of Gastroenterology and European Society of Gastrointestinal Endoscopy provide strong recommendations (based on low-quality evidence) that warfarin should not be withheld for low-risk procedures. 1

INR Monitoring Requirements

• Check INR during the week before the procedure to ensure it is within therapeutic range and does not exceed 3.5. 1
• If INR is within therapeutic range (typically 2.0-3.0), continue with the usual daily warfarin dose. 1
• If INR is above therapeutic range but less than 5.0, reduce the daily warfarin dose until INR returns to therapeutic range. 1
• If INR exceeds 3.5 before the procedure, defer the cystoscopy until INR is controlled. 1

Special Considerations for Therapeutic Cystoscopy

If the cystoscopy involves therapeutic interventions (such as transurethral resection of bladder tumors, which would be classified as high-risk):

• Stop warfarin 5 days before the procedure for patients at low thromboembolic risk. 1
• Check INR prior to procedure to ensure it is <1.5. 1
• For patients at high thromboembolic risk (mechanical heart valves, recent thromboembolism, atrial fibrillation with high stroke risk), warfarin should be stopped 5 days before the procedure and bridged with therapeutic-dose low molecular weight heparin (LMWH). 1
• Start LMWH 2 days after stopping warfarin, with the last dose administered at least 24 hours before the procedure. 1

Post-Procedure Management

• Patients should be advised that there is an increased risk of post-procedure bleeding compared to non-anticoagulated patients, even when warfarin is continued. 1
• If warfarin was discontinued, restart on the evening of the procedure with the usual daily dose. 1
• If bridging was used, restart therapeutic-dose LMWH the day after the procedure and continue until INR reaches therapeutic range. 1

Common Pitfalls

• Do not routinely stop warfarin for simple diagnostic cystoscopy - this creates unnecessary thromboembolic risk without meaningful reduction in bleeding risk. 1
• Always verify the type of cystoscopy planned - diagnostic versus therapeutic procedures have completely different management strategies. 1
• Failing to check INR before the procedure can lead to performing the procedure with supratherapeutic anticoagulation. 1