What is the management approach for hematuria (blood in urine) with associated groin pain occurring 26 days after a Transurethral Resection of the Prostate (TURP) procedure?

Management of Hematuria with Groin Pain 26 Days Post-TURP

This delayed hematuria occurring nearly 4 weeks after TURP requires immediate evaluation for secondary hemorrhage, with urgent cystoscopy to identify and cauterize bleeding vessels, while ruling out infection and bladder perforation as potential causes of both hematuria and groin pain.

Immediate Assessment and Stabilization

Initial Evaluation

• Assess hemodynamic stability and obtain complete blood count to quantify blood loss, as bleeding complications occur in approximately 8% of TURP cases requiring transfusion 1
• Obtain urine culture immediately to rule out urinary tract infection, which is a common complication following TURP, particularly in patients who had preoperative urinary retention 2
• Evaluate for clot retention through bladder ultrasound or catheterization, as clot retention is a recognized post-TURP complication that can cause pain and hematuria 3

Groin Pain Considerations

• The groin pain raises concern for bladder perforation or delayed ureteral injury, particularly if the pain is unilateral and corresponds to the left side, as perforations near the trigone and ureteral orifice can present with delayed symptoms 4
• Consider deep vein thrombosis in the differential diagnosis, as the incidence of symptomatic venous thromboembolism within 91 days of TURP ranges from 0.3% to 0.5% 5

Definitive Management

Cystoscopic Intervention

• Perform urgent cystoscopy with cauterization of any identified bleeding vessels, as this is the standard approach for secondary hemorrhage after TURP 6, 7
• During cystoscopy, carefully inspect for bladder perforation, particularly near the trigone and ureteral orifices, as delayed recognition of perforation can lead to serious complications 4
• If active bleeding is identified, achieve meticulous hemostasis using electrocautery through the resectoscope 7

Catheter Management

• Place a large-caliber urethral catheter (20-24 Fr) with continuous bladder irrigation to manage ongoing hematuria and prevent clot formation 4
• Consider brief catheter traction (10 minutes) if bleeding persists after cauterization, as this can provide adequate hemostasis with less morbidity than prolonged traction 3

Anticoagulation Considerations

If Patient is on Anticoagulation/Antiplatelet Therapy

• Review the patient's anticoagulation status, as resumption of anticoagulation is typically delayed for at least 24 hours postoperatively or until bleeding has almost completely subsided 5
• If the patient resumed anticoagulation prematurely, this could explain the delayed hemorrhage at 26 days, as major and minor bleeding occurred in 9.5% of procedures in anticoagulated patients 5
• Bridging with LMWH should be continued until INR is within therapeutic range on two separate measurements if warfarin was restarted 5

Infection Management

Antimicrobial Therapy

• If urine culture is positive, initiate targeted antimicrobial therapy based on culture sensitivities, as urinary tract infections are more common in patients with acute urinary retention who underwent TURP 2
• Consider empiric broad-spectrum antibiotics while awaiting culture results if the patient shows signs of systemic infection, as adequate prophylactic antibiotic treatment decreases the risk of urinary tract infection after TURP 2

Surgical Intervention for Complications

If Bladder Perforation is Identified

• Immediate surgical exploration is indicated if perforation is confirmed near the ureter orifice, with options including laparoscopic repair or open surgical repair with possible ureteral reimplantation 4
• Perform cystogram before catheter removal to confirm healing if perforation is managed conservatively 4

If Bleeding Cannot Be Controlled Cystoscopically

• Consider repeat TURP or open surgical intervention for uncontrolled hemorrhage, though this is rarely necessary 1

Post-Intervention Monitoring

Short-Term Follow-Up

• Monitor hemoglobin levels serially to ensure stabilization after intervention 1
• Continue catheter drainage for 24-48 hours after bleeding subsides, with gradual reduction of irrigation rate 7
• Assess for signs of infection, including fever, dysuria, and pyuria, as these complications can occur between hospital discharge and follow-up 1

Long-Term Considerations

• Schedule follow-up cystoscopy at 3 months if there was concern for perforation or significant tissue injury 4
• Monitor for late complications requiring endourological re-intervention, which occur in approximately 9.7% of patients within five years 1

Common Pitfalls to Avoid

• Do not attribute all delayed hematuria to "normal post-TURP bleeding" at 26 days, as this timing suggests secondary hemorrhage or another complication requiring intervention 6, 7
• Do not overlook the significance of groin pain, as this may indicate extraurethral pathology such as perforation, ureteral injury, or thrombosis 4
• Do not delay cystoscopy in favor of conservative management when hematuria is significant or accompanied by pain, as early intervention prevents progression to clot retention and potential bladder tamponade 3