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ORIGINAL ARTICLE
Year : 2014  |  Volume : 17  |  Issue : 3  |  Page : 79-82

Bleeding prostate: A 10-year experience in the University of Maiduguri Teaching Hospital (Umth), Nigeria


Department of Surgery, University of Maiduguri Teaching Hospital and College of Medical Sciences University of Maiduguri, India

Date of Web Publication6-Sep-2014

Correspondence Address:
Nuhu Ali
Department of Surgery, University of Maiduguri Teaching Hospital, PMB 1414 Maiduguri, Borno State
India
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DOI: 10.4103/1118-8561.140284

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  Abstract 

Background: Bleeding from an enlarged prostate gland is a major complication of benign prostatic enlargement (BPH). This review details our management over a 10-year period. Materials and Methods: A retrospective review of patients who presented with bleeding BPH between January 2001 and December 2010 was carried out to determine the outcome of management.
Results: Forty-two patients with bleeding prostates treated by open prostatectomy were analyzed. The peak incidence was in the age group of 60-69 years. The main associated co-morbidities were hypertension in 17 (40.48%) and diabetes in seven (16.67) patients. Urine culture was positive in 24 (57.14%) patients, with E. coli in 13 (54.17%) and Pseudomonas in four (16.67%) patients as the main isolates. Most patients (37; 88.08%) received blood transfusions ranging from two to four units. Operative techniques were transvesical in 30 (76.92%) and retropubic in nine (23.08%) patients. Isolated median lobe enlargement of the prostate was seen in 18 (46.15%) and whole organ enlargement in 21 (53.85%) patients. The weight of the prostates ranged from 47 to 403 g (mean, 127 g). Incidental carcinoma was seen in one patient (2.56%). The mean hospital stay was 11 days (range 9-21), and the mean follow-up was 21 months (range 3-26). There was one (2.38%) mortality. Conclusion: BPH with massive hematuria invariably has an enlarged median lobe and is managed by open prostatectomy, without risk of re-bleeding.

Keywords: Benign prostatic hyperplasia, bleeding, open prostatectomy


How to cite this article:
Ahmed GI, Aliyu S, Ali N. Bleeding prostate: A 10-year experience in the University of Maiduguri Teaching Hospital (Umth), Nigeria. Sahel Med J 2014;17:79-82

How to cite this URL:
Ahmed GI, Aliyu S, Ali N. Bleeding prostate: A 10-year experience in the University of Maiduguri Teaching Hospital (Umth), Nigeria. Sahel Med J [serial online] 2014 [cited 2019 Oct 15];17:79-82. Available from: http://www.smjonline.org/text.asp?2014/17/3/79/140284


  Introduction Top


Bleeding is one of the lower urinary tract symptoms seen in patients with benign prostatic hyperplasia and can be a significant problem requiring catheter placement or other acute intervention. [1] Clinically, patients present with hematuria, which is rarely so massive to cause hemodynamic instability. When bleeding is massive, it poses a great challenge to the surgeon, especially in the developing world, where facilities for endourology and minimal access surgery are limited. The challenge is not only in differentiating bleeding prostate from bladder tumors but also in dealing with associated complications of bleeding prostatic enlargement (BPH) and co-morbid medical conditions in this category of patients. This is further compounded by late presentation even in patients with BPH and advancing age, which is common to both conditions. [2],[3] In developed countries, where state of the art facilities abound, the treatment options range includes non-operative measures (irrigation and instillation with thrombin solution), minimally invasive procedures such as transurethral electrovaporization (TUVP) and prostatic arterial embolization. [4],[5],[6]

The aim of this study was to review our 10-year experience with bleeding prostates, with an emphasis on the challenges in the management of these patients in a center with limited facilities.


  Materials and methods Top


All patients who presented with bleeding BPH at the University of Maiduguri Teaching Hospital (UMTH) between January 2001 and December 2010 were retrospectively reviewed. Details of their bio data, clinical presentations, diagnostic investigations, operative treatment, histological reports, post-operative complications and other outcome of management were extracted and analyzed. Written permission and clearance were sought and obtained from the hospital's Medical Ethics and Research Committee. Results of urinalysis, urine culture, ultrasound scan, cystoscopy and blood chemistry were analyzed. Additional tests like prostate-specific antigen (PSA) and prostatic biopsy were reserved for patients with a suspicion of malignancy, and those confirmed were excluded from the study. Patients received an antibiotic based on the organism isolated from the urine and their sensitivity. All patients had initial conservative management, which included irrigation with saline, povidon iodine and 5% alum, aimed at controlling bleeding and achieving hemodynamic stability, optimizing patients for open prostatectomy. All the patients were transfused. The study excluded patients who opted for drug treatment of BPH after control of bleeding.


  Results Top


A total of 47 patients were included in this study. Forty-two patients were analyzed. Thirty-nine patients had open prostatectomy while three patients below the age of 50 years declined surgery and opted for medical treatment of BPH. Five patients were excluded from the study as there was incomplete data. [Table 1] shows the age distribution, with a peak incidence of bleeding prostate in the age group of 60-69 years. Associated co-morbidities were hypertension in 17 (40.48%), diabetes in seven (16.67), arthritis in six (14.29%) and HIV in three (7.14%) patients; the others were asthma and drug allergy in one (2.38%) patient each. Urine culture was positive in 24 (57.14%) and negative in 18 (42.86%) patients. Isolates were E. coli in 13 (54.17%), Pseudomonas in four (16.67%) and Proteus and Klebsiella in two (8.33%) patients each, while three (12.5%) patients grew mixed organisms. [Table 2] outlines the complications at presentation where acute urinary retention accounted for over 50%. All the patients received between two and four pints of blood transfusion. Four (9.52%), 18 (42.86%) and 15 (35.71%) patients received more than four, three to four and two or less units, respectively, while five (11.90%) patients had no transfusion. All patients who underwent surgical operations had either spinal 30 (76.92%) or general nine (23.08%) anesthesia. The operative technique was transvesical in 30 (76.92%) and retropubic in nine (23.08%) patients. [Table 3] shows the intraoperative findings; there was median lobe enlargement in most cases of bleeding prostates. [Table 4] shows the intraoperative findings, with isolated median lobe enlargement of the prostate in 18 (46.15%) and whole organ enlargement in 21 (53.85%) patients; thus, median lobe enlargement was present in all 39 (100%) patients presenting with bleeding BPH. The weight of the prostates removed ranged from 47 to 403 g, with a mean of 127 g. Histology revealed BPH in 38 (97.44%) patients and a focus of adenocarcinoma in background BPH in one (2.56% incidental carcinoma) patients. The average hospital stay was 11 days, with a range of nine to 21 days. The follow-up period ranged from 3 to 36 months, with a mean of 21 months. There was one (2.38%) mortality, resulting from acute renal failure at the time of recovery from prostatectomy.
Table 1: Age distribution

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Table 2: Complications at presentation

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Table 3: Intraoperative fi ndings

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Table 4: Post-operative complication

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  Discussion Top


Massive hematuria due to BPH, although uncommon, is often associated with hemodynamic instability that requires urgent resuscitative measures, including volume replacement, control of bleeding and subsequent definitive treatment of the enlarged prostate. In developed countries where facilities are available, minimally invasive techniques are the treatment of choice after resuscitation. [7] In our experience, open prostatectomy is the mainstay of treatment because we have limited facilities. Moreover, our patients present late and with complications of BPH like stones, diverticulae, hernias and larger prostates, all of which are indications for open prostatectomy. [8] Elderly patients with co-morbid medical conditions such as diabetes and hypertensive heart disease presenting with BPH complicated by bleeding and renal or cardiac failure are best treated by open prostatectomy [9] after initial resuscitation.

Forty-seven patients with bleeding enlarged prostates were treated over a 10-year period, giving an average of 4.7 per year in our center, which is similar to the finding by Sharfi et al. in Khartoum Sudan. [10] The peak age of patients presenting with bleeding prostates is not different from that of LUT symptoms from an enlarged gland, which seems to suggest that advanced age may not be directly linked to the bleeding. However, urinary tract infection, large volume prostates, systemic hypertension and anticoagulant therapy are known to be associated with bleeding BPH. [11],[12]

This study showed that all patients had median lobe enlargement either as an isolated event or a component of a global prostatic enlargement. This has a causal relationship with prostatic bleeding because, as the median lobe enlarges into the bladder (open space), the neo-capillaries on its surface easily rupture and bleeds on straining, especially when complicated by urinary tract infection or bladder stone.

Massive prostatic bleeding is very startling to the patient and can cause a lot of challenges to the surgeon, especially if the patient is hemodynamically unstable. However, in this study, basic resuscitative measures including blood transfusion, fluid replacement and measures to control bleeding, such as irrigation with saline, povidone iodine and alum, were performed singly or in combination, with good results. These methods of control of bleeding were sufficient and comparable to more advanced methods like prostatic arterial embolization and irrigation with thrombin solution. [13],[14] Emergency prostatectomy may be necessary in massive and intractable bleeding as reported by Ramyil et al.[19] in Jos, Northern Nigeria.

This study revealed that open prostatectomy is a formidable option for treating BPH presenting with bleeding after initial resuscitation. Prostatectomy is performed on the next available operation list without discharging the patient because once bleeding has occurred, the chance of more episodes exists. [15] Minimal invasive techniques such as TURP, [10] LASER [9] and needle ablation [7] are highly successful in the definitive treatment of bleeding BPH where available. Another option after full resuscitation is drug treatment with oral Finastride. [16] We found open prostatectomy, especially transversical, to be successful in controlling bleeding and dealing with other pathologies in the bladder (stone and diverticuli); moreover, it is not known to be associated with re-bleeding.

The post-operative complications are similar to those of non-bleeding BPH. [17],[18] There was one mortality due to disseminated intravascular coagulation, giving a mortality rate of 2.4%, which was in contrast with the findings by Ramyil et al.,[19] in Jos, who reported a mortality rate of 10.8%.

In conclusion, despite the life-threatening presentation of a bleeding prostate (BPH), its management by initial resuscitation and subsequent definitive transversical prostatectomy is associated with gratifying results, with minimal morbidity and almost no re-bleeding.

 
  References Top

1.Mcvary KT. Clinical evaluation of benign prostatic hyperplasia. Rev Urol2003;5:S3-S11.  Back to cited text no. 1
    
2.Yonon H, Goya M, MiyazatoM, Sugaya K, Hatano T, Ogawa Y. Giant prostatic hypertrophy: A case report. Hinyokikakiyo 1990;36:1167-72.  Back to cited text no. 2
    
3.Mei-ju C, Cheng-yi L, Shwu-cheng W.The prevalence of chronic conditions and medical expenditures of the elderly by chronic conditionindicator (CCI). Arch GerontolGeriatr2011;52:284-9.  Back to cited text no. 3
    
4.Dhingra N, Bhagwat D. Benign prostatic hyperplasia: An overview of existing treatment. Indian J Pharmacol 2011;43:6-12.  Back to cited text no. 4
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5.Thomson IM, Teague JL, Mueller EJ, Rodriguez FR. Intravesical alum irrigation for intractable bleeding secondary to carcinoma of the prostate. J Urol 1987;137:525-6.  Back to cited text no. 5
    
6.Mitchell ME, Waltman AC, Athanasoulis CA, Kerr WS Jr, Dretler SP. Control of massive prostatic bleeding with angiographic techniques. J Urol 1976;115:692-5.  Back to cited text no. 6
    
7.NaslundMJ. "TUNA versus TURP''The cost comparison. J Urol 1997;157:155.  Back to cited text no. 7
    
8.Cabelin MA, TeAE, Kaplan SA. Transurethral vaporization of the prostate: Current techniques. Curr Urol Rep 2000;1:116-23.  Back to cited text no. 8
    
9.Ahmed Gadam I, Nuhu A, Aliyu S. Ten -Year Experience with Open Prostatectomy in Maiduguri. ISRN Urol 2012;2012:406872.  Back to cited text no. 9
    
10.Sharfi AR, Hassan O. Evaluation of haematuria in Khartoum, Sudan. East Afr Med J 1994;71:29-31.  Back to cited text no. 10
    
11.Guo LJ, Tang Y, Guo CM, Zhang XH. Impact of primary hypertention on haematuria of the patients with benign prostatic hyperplasia. Chin Med J (Engl) 2010;123:1154-7.  Back to cited text no. 11
    
12.Annthoniewicz AA, Zapa³a L, Poletajew S, Borówka A. Macroscopic haematuria- A leading urological problem in patients on anticoagulant therapy; Is the common Diagnostic standard still advisable? ISRN Urol 2012;2012:710734.  Back to cited text no. 12
    
13.Rastinehad AR, Caplin DM, Ost MC, VanderBrink BA, Lobko I, Badlani GH et al. Selective arterial prostatic embolization (SAPE) for refractory haematuria of prostatic origion. Urology 2008;71:181-4.  Back to cited text no. 13
    
14.Mitsubayashi S, Kurita T, Kataoka K, Iguchi M, Kadowaki T. The manage ment of bleeding following transurethral prostatic resection by local irrigation with a thrombin solution. Hinyokikakiyo 1986;32:1371-7.  Back to cited text no. 14
    
15.Kashif KM, Foley SJ, Basketter V, Holmes SA. Haematuria associated with BPH-Natural history and a new treatment option. Prostate Cancer Prostatic Dis 1998;1:154-6.  Back to cited text no. 15
    
16.Sieber PR, Rommel FM, Huffnagle HW, Breslin JA, Agusta VE, Harpster LE.The treatment of gross haematuria secondary to prostatic bleeding with Finasteride.JUrol 1998;159:1232-3.  Back to cited text no. 16
    
17.Kadir C.Open prostatectomy; The results of a series of 320 cases in rural area.Eur J Gen Med 2006;3:11-5.  Back to cited text no. 17
    
18.Salim K, AsgharK, Azizmarjan K. Surgical treatment of benign prostatic hyperplasia: Outcome of transvesical prostatectomy. E/Biomedica/New Journal 2004;20:Bio-3. Doc (A).  Back to cited text no. 18
    
19.Ramyil VM, Dakum NK, Liman HU, Udeh EI. The management of prostatic haematuria.Niger J Med 2008;17:439-42.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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