What are the symptoms and treatment options for bleeding from the prostate?

Bleeding from the Prostate: Symptoms and Treatment

Prostatic bleeding in benign prostatic hyperplasia (BPH) should be treated with a 5-alpha reductase inhibitor (finasteride or dutasteride) as first-line medical therapy, with surgery reserved for recurrent gross hematuria refractory to medical management. 1

Clinical Presentation and Symptoms

Gross hematuria is the primary symptom of prostatic bleeding, though it is an uncommon complication of BPH. 1 The bleeding originates from the friable hypervascularity of the enlarged prostate, where vessels are easily disrupted by physical activity. 2, 3

Key diagnostic considerations:

• Gross hematuria must be proven to be of prostatic origin through appropriate evaluation before attributing it to BPH 1
• Rule out other urological causes (bladder cancer, stones, infection, upper tract sources) through cystoscopy, imaging, and urinalysis 1
• Medical therapy is contraindicated in patients who have not been adequately evaluated or in patients with microscopic hematuria alone 1

Treatment Algorithm

First-Line Medical Management

5-alpha reductase inhibitors (finasteride 5 mg daily) are highly effective for prostatic bleeding:

• In a retrospective series of 24 patients treated with finasteride, 20 patients (83%) had complete resolution of bleeding with mean 9-month follow-up 2
• Only one patient experienced minor intermittent bleeding requiring no further treatment 2
• The mechanism works by suppressing angiogenesis through androgen deprivation 3
• This approach should be considered the standard treatment for prostatic bleeding secondary to BPH 2

Natural History Without Treatment

Untreated prostatic bleeding can be significant:

• In 18 untreated patients (mean age 70 years), only 9 (50%) had spontaneous resolution 2
• Six patients (33%) had several bleeding episodes, with three ultimately requiring TURP 2
• This demonstrates that observation alone is inadequate for most patients 2

Surgical Intervention

Surgery is recommended for recurrent gross hematuria clearly due to BPH and refractory to medical therapy. 1 This represents an absolute indication for surgical management when medical treatment fails.

Surgical options include:

• Transurethral resection of the prostate (TURP) - the benchmark surgical therapy 1
• Open prostatectomy for prostates >80-100 mL 1
• Laser procedures (though these may paradoxically cause delayed hematuria themselves) 4

Important Caveats and Pitfalls

Common pitfall: Starting medical therapy without adequate evaluation. Always exclude malignancy and other causes before attributing bleeding to BPH. 1

Anticoagulation considerations: Patients on anticoagulation have significantly higher risk of delayed bleeding after prostatic procedures (OR 3.35), making medical management with 5-alpha reductase inhibitors even more important in this population. 4

Protective factors: Preoperative use of 5-alpha reductase inhibitors reduces the risk of delayed hematuria after prostatic procedures (OR 0.41), supporting their use prophylactically in high-risk patients. 4

Side effects to counsel: Finasteride causes sexual dysfunction (decreased libido 6.4%, impotence 8.1%, decreased ejaculate volume 3.7% in year 1) and rarely gynecomastia (0.5-1.8%). 5 In the treatment series, one patient stopped finasteride due to impotence and one developed mild gynecomastia. 2

Radiation-related bleeding: For patients with history of prostate radiation therapy, prostatic bleeding may represent radiation proctitis rather than BPH, requiring different management including endoscopic coagulation. 6, 7