What is the differential diagnosis for hematuria with clots 26 days post Transurethral Resection of the Prostate (TURP)?

Differential Diagnosis for Hematuria with Clots 26 Days Post-TURP

The most likely diagnosis is delayed secondary hemorrhage from sloughing of necrotic prostatic tissue, which typically occurs during the second week post-TURP (median 11th day), though bladder tumor, bladder perforation complications, and anticoagulation-related bleeding must be excluded. 1

Primary Differential Diagnoses

1. Delayed Secondary Hemorrhage from Prostatic Sloughing (Most Likely)

• This is the classic presentation of post-TURP hematuria occurring at 26 days, as necrotic tissue sloughs from the resection bed during weeks 2-4 post-procedure. 1
• The pathophysiology involves delayed separation of coagulated tissue and eschar from the prostatic fossa, exposing underlying vessels. 1
• This complication occurs in approximately 1.6% of TURP cases (10 of 624 patients in one series) and typically presents with gross hematuria and clot retention requiring hospitalization. 1
• The median time to presentation is 11 days post-TURP, though it can occur throughout the first month. 1

2. Bladder Tumor (Must Exclude)

• Hematuria with clots is the most common presenting symptom of bladder cancer, and cystoscopy must be performed to exclude a bladder lesion. 2
• This is particularly important as 2 of 10 patients in one series presenting with post-TURP hematuria were ultimately diagnosed with prostate cancer on pathology review, highlighting the need to exclude concurrent malignancy. 1
• The European Association of Urology guidelines prioritize cystoscopy for macrohematuria with clots as a higher-priority procedure. 2

3. Anticoagulation/Antiplatelet Therapy Complications

• Patients on anticoagulation or antiplatelet therapy have significantly increased bleeding risk post-TURP, with 23% requiring early postoperative blood transfusion when anticoagulation is recommenced. 2
• The timing at 26 days coincides with full resumption of anticoagulation therapy, which typically occurs once INR is therapeutic on two separate measurements. 2
• Review medication history specifically for warfarin, clopidogrel, aspirin, or direct oral anticoagulants (DOACs). 2

4. Bladder Perforation with Delayed Presentation

• Bladder perforation during TURP, particularly near the trigone, can present with delayed complications including hematuria, though this would more typically present earlier. 3
• Fat visualization near the trigone during the original procedure would indicate perforation requiring immediate management. 3
• Extraperitoneal perforations can become intraperitoneal if not addressed promptly. 3

5. Prostatic Infarction (Rare)

• Prostatic infarction involving the urinary sphincter can present with hematuria and restrictive urinary symptoms years after TURP, though this is exceedingly rare. 4
• This diagnosis should be considered if necrotic tissue is visualized on cystoscopy without evidence of malignancy. 4

6. Urinary Tract Infection with Secondary Bleeding

• Patients with acute urinary retention pre-TURP are at greater risk of postoperative urinary tract infections, which can cause secondary hematuria. 5
• UTI occurs in more than 5% of TURP cases and is more frequent following complicated procedures. 2, 3

Immediate Diagnostic Workup

Essential Investigations

• Office cystoscopy to visualize the bladder and prostatic fossa, looking for bleeding sites, residual prostatic tissue, bladder tumors, or evidence of perforation. 2
• Complete blood count to assess hemoglobin/hematocrit and need for transfusion (approximately 8% of TURP patients require transfusion for bleeding). 6
• Coagulation studies (PT/INR, aPTT) if patient is on anticoagulation. 2
• Urinalysis and urine culture to exclude infection. 5
• Review of original TURP operative report for complications, resection weight, and duration. 1

Additional Considerations

• CT urography if upper tract source suspected or if cystoscopy is non-diagnostic. 2
• Serum creatinine to assess renal function, particularly if clot retention has caused obstruction. 5

Management Algorithm

Initial Management (All Patients)

• Place large-caliber urethral catheter (20-24 Fr) with continuous bladder irrigation to manage clot retention and prevent obstruction. 3
• Assess hemodynamic stability and transfuse if hemoglobin <7-8 g/dL or symptomatic anemia. 1
• Hold anticoagulation temporarily if safe from thrombotic standpoint (requires individualized risk assessment). 2

Definitive Management Based on Etiology

• For prostatic sloughing: Continuous bladder irrigation with large-bore catheter is typically sufficient; reoperation or clot evacuation under general anesthesia is rarely required. 1
• For persistent bleeding despite conservative measures: Consider repeat TURP or fulguration of bleeding vessels. 1
• For bladder tumor identified: Stage appropriately and plan transurethral resection of bladder tumor (TURBT) once acute bleeding controlled. 2
• For anticoagulation-related bleeding: Delay resumption of anticoagulation until bleeding subsides (at least 24 hours postoperatively per bridging protocols). 2

Critical Pitfalls to Avoid

• Do not assume all post-TURP hematuria is benign sloughing without performing cystoscopy to exclude bladder cancer or other pathology. 2, 1
• Do not restart anticoagulation until bleeding has almost completely subsided, as premature resumption increases transfusion risk to 23%. 2
• Do not perform cystogram before catheter removal without first confirming no perforation occurred during original TURP. 3
• Recognize that patients with larger prostates and more tissue resected are at higher risk for complications. 5

Expected Outcomes

• Most patients with delayed hemorrhage from sloughing respond to conservative management with catheter drainage and irrigation. 1
• Two patients in one series required transfusion, but no patients required reoperation. 1
• Full recovery typically occurs within 4-6 weeks of the original TURP procedure. 7