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What Causes Severe Bleeding During Urination Post Ureteroscopy With Lithotripsy?

Posted on Wed, 8 Apr 2015

Question: Concerned for my 34 yr old son. He has no PMH, no bleeding disorder. Had 1st ever episode of renal calculi on 3/3/15. Urologist did ureteroscopy with lithotripsy and basket extraction of 5mm stone 10 days ago. A stent was left in place. Two days later he had to be rehospitalized for acute urinary retention, large clot of 7 cm diameter in bladder, hematuria with large clots. Foley was placed. After two days foley and stent were removed. He still continues to have episodes of urinating bright red blood with clots. On 3/14 was in the ED again with bleeding, clots and pain. CAT scan without contrast showed edema and swelling of ureter. The drs states the bleeding should eventually stop and they don't want to do another procedure as it "might make things worse". My question is: Have you ever seen anything like this? Could it be due to spasms and if so, what would you recommend? Should he have any other testing?
Cat scan result was:
Mild asymmetric thickening of the left distal ureter without obstructive
hydroureteronephrosis, could represent ureteritis. No filling defect identified of the
bladder. No renal, ureteral or bladder calculi. Please correlate with urinalysis.

Answered by Dr. Dr. P. T. Patil (3 hours later)

Brief Answer:
read Detail answer below.

Detailed Answer:
Hello
Thanks for your query,based on the facts that you have posted it appears that your 34 years old son has undergone URS plus ICSWL for left Ureteric Calculus and have severe bleeding post surgery
.
I shall be happy if you can post me few more details to help me in making comments on your problem.
1) Where was the stone located ?
2) What was the size of the stone reported on ultrasound Scanning ?
3) Was there infection prior to surgery?
4) Was the hydronephrosis on affected side to be severe ,mild ,or moderate ?

The most possible cause for bleeding is likely to be due to one of the two following common reasons
1) Infection (Ureteritis ) which always exists due to impacted stone ?
2) Injury to Ureteric mucosa while fragmenting the stone and retrieving the fragments by basket.

In a given scenarios the plan of action what I think is as follow
1) Wait and watch with bladder catheter in place with continuous drainage .
2) Give higher antibiotics as per culture report
3) Adequate I.V fluids so that urine output remains in the range of 1500-2000 ml
4) Inj Drotaverine,Botrophase twice daily .
5) Tab Tomsulosin once daily.

Most of the time bleeding stops with this regime .

If problem persists he may need to visualize the ureter and bladder by endoscopy(Flexible Ureteroscopy) to trace out site and source of bleeding and to fulgurate bleeding point.

Hope I have answered your query ,please feel free to ask if you have more questions
I shall be happy to help you
Thanks and Regards.
Dr.Patil.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Dr. P. T. Patil (23 hours later)

The stone was described on CT scan as 5mm obstructive calculus within left distal ureter. There was no obvious infection, no fevers, but initial white blood cell count was 11.98 with neutrophils 9.75. Urine culture apparently was not done. Creatinine was 1.47. He did receive several doses of ciprofloxacin while hospitalized. The hydronephrosis was described as mild. As of 3/14 white blood cell count is 7.95. BUN is 21. Urinalysis is positive for protein, positive for nitrates, small amount leukocytes, trace ketones and large amount of blood. I do not think Drotaverine nor Botrophase are available here in USA. He is taking Tamsulosin already. On 3/6 an ultrasound showed a large hematoma or clot, 7cm in greatest diameter. The latest imaging shows the hematoma or clot is no longer there. He continues though to have episodes of large amounts of bright red bleeding with large clots with difficulty voiding at times. My main concern is that 13 days after the procedure he still has so much bleeding.
Would steroids or non steroidal anti-inflammatory medications be indicated
at all? Any other recommendations?

Answered by Dr. Dr. P. T. Patil (19 minutes later)

Brief Answer:
read detail answer below.

Detailed Answer:
Hello
Thanks for feedback and follow up.

Persistent bleeding has to be taken seriously.

If his bleeding continues even after taking antibiotics,and I.V fluids for 5 days I would suggest to discuss with your treating Urologist to consider inspection of interior of ureter by doing Ureteroscopy and to fulgurate the bleeding point .

Steroids have no place in when there is active bleeding .

Dratoverine and Botrophase should be available in US.

Thanks and Regards.
Dr.Patil.

Above answer was peer-reviewed by : Dr. Yogesh D

Follow up: Dr. Dr. P. T. Patil (1 hour later)

Thank you so much for your help. It just has been worrisome and I hate to see my son in so much discomfort and with all this bleeding. I just wanted a "second opinion" basically.

Answered by Dr. Dr. P. T. Patil (2 hours later)

Brief Answer:
Welcom.

Detailed Answer:
Hello
Thanks or follow up. I have faced such situations for number of times in my 41 years of practice and tried to advise you based on my knowledge and experience .Hope it will help you to allay your worry and tension.

Would be glad to hear about future course of actions and outcome of treatment that will be given to him. It may be more addition to my knowledge.

Please post your review about my advice and suggestions on forum of Health Care Magic..

Thanks and Regards.
Dr.Patil.

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Above answer was peer-reviewed by : Dr. Prasad