for
- continue to trend UOP and bladder scan pt if she is unable to void or passing small volume
- continue to trend Hgb and Cr
- if hemoglobin downtrending or hematuria worsens or pt unable to void,please contact urology as pt may require further interventions such as manual bladder irrigation
- if approprriate continue to hold warfarin
- urine cytology
- need cystoscopy and possible MRU/CTU as an outpatient pending renal function
- pt discussed with Dr. Guruli
UPTODATE>
Initial management — The initial management of HC varies based on condition severity:
●For patients with mild HC (ie, grade 1 (table 2), including those with gross hematuria without clots, adequate bladder emptying (as assessed by postvoid residual), and lower urinary tract symptoms, conservative measures, including hydration and anticholinergic bladder medications (as needed for bladder spasms), may be used in an outpatient setting after urinalysis and urine culture to exclude infection [83].
●For patients presenting with the passage of blood clots (moderate or severe HC), initial management includes assessment of hemodynamic stability, hydration (or transfusion if needed), and ensuring adequate bladder drainage. Typically, in these scenarios, patients are admitted to the hospital for observation and interventions. (See 'Tempo and location of the evaluation'above.)
A large-bore (≥22 Fr) three-way Foley catheter is placed to allow for manual clot irrigation with saline. (See "Placement and management of urinary bladder catheters in adults", section on 'Specialized catheters'.)
If the urine clears following manual irrigation, subsequent conservative management with hydration alone may be sufficient. If the hematuria or clots persist despite manual catheter irrigation, CBI with normal saline may be initiated. Ensuring adequate fluid outflow from the three-way catheter while on CBI is important because if the outflow channel becomes blocked, the bladder will continue to distend with the fluid being instilled, which risks perforation. Notably, outflow obstruction can present as worsening abdominal pain or persistent bladder spasms.
●If the three-way catheter has repeated obstruction, the clots cannot be removed by hand irrigation, or the patient does not improve with saline CBI, the next step is cystoscopy under anesthesia. While there are no data on the time to resolution with saline CBI alone, without repeated obstruction, we typically utilize this strategy for two to four days if the above conditions are not met and the patient's hemodynamic parameters allow. Proceeding with cystoscopy under anesthesia allows for clot evacuation (picture 1), fulguration of bleeding vessels (if they are identified), and management of any bladder tumors (if present). Notably, given the typical diffuse mucosal bleeding in HC, identifying a discrete bleeding vessel is not common. In one report of 33 patients with HC associated with cyclophosphamide or RT, 14 (42 percent) had resolution of hematuria after a single cystoscopy under anesthesia including clot evacuation or fulguration [84]. Only 4 of 11 patients who initially did not respond had resolution after a total of two or more cystoscopies.
Traditionally, cystoscopic bladder fulguration has been accomplished with electrocautery; however, some small case series note successful use of lasers for coagulation [85,86]. In these studies, a GreenLight potassium titanyl phosphate (KTP) laser (530 nm wavelength) and a 980 nm diode laser were used to manage radiation-induced HC. In an additional study, a GreenLight Xcelerated Performance System (XPS) laser (1064 nm wavelength) was successfully used in four patients who had previously failed fulguration with electrocautery [87]. Notably, attention must be paid to the depth of laser penetration and the risk of bladder perforation, as intestinal perforation and subsequent death following laser coagulation for radiation cystitis in a female patient have been reported [88].
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