Tuesday, November 28, 2023
Prostatic hematuria can be a challenging clinical problem. In this Review we discuss the spectrum of methods for diagnosing prostatic hematuria and the pharmacologic and minimally invasive therapies currently available to treat primary disease and refractory cases. Before making a diagnosis and starting therapy, however, other, nonprostatic sources of hematuria must be ruled out. As part of diagnosis all patients should undergo a formal cystoscopy. Therapy should include functional and biochemical approaches. Inhibitors of 5-α-reductase have been shown to successfully treat prostatic hematuria when it is caused by benign prostatic hyperplasia. Intravesical instillations, using agents such as alum, silver nitrate and formalin, have been used as second-line therapies, with limited success. A novel, minimally invasive method, termed selective arterial prostatic embolization, offers another option for treating prostatic hematuria. Using interventional radiologic techniques during selective arterial prostatic embolization enables selective catheterization of the prostatic arterial circulation with subsequent embolization. This approach can rapidly stop hematuria. If more-invasive therapy is required, transurethral resection, or vaporization of the prostate and clot evacuation, should be performed before embolization or other surgical interventions.
Recurrent prostatic bleeding can be a challenging and frustrating clinical problem. Persistent bleeding can lead to severe morbidity and, in the case of severe bleeding, might lead to hospitalization and blood transfusions. The repetitive irrigation often required to alleviate the bleeding has the potential to cause sepsis as well as bladder rupture. In patients with additional comorbidities, life-threatening events, such as stroke and myocardial infarction, might occur.
The incidences of hematuria associated with prostate cancer, radiation therapy and benign prostatic hyperplasia are 0.7%, up to 5.0%, and 20.0%, respectively. The treatment of gross hematuria has historically consisted of a functional approach. The current treatment paradigm has, however, evolved to include the use of 5-α-reductase inhibitors and androgen deprivation therapy, depending on the etiology of the bleeding.
In this article we review the causes of prostatic hematuria as well as provide a guide to the current available therapies.
