Unusual Presentation of Bladder Tumour: Haematuria only after Administration of Anti-Platelet Drugs
Correspondence Address :
Stephen Lalfak Zuala Sailo,
A-19, Faculty Quarters, NEIGRIHMS, Shillong, Meghalaya, India.
E-mail: stephensailo@gmail.com
Anti-thrombotic agents are used for the treatment and prevention of cardiovascular diseases. Bleeding is the most important side-effect of these agents. The common causes of haematuria after anti-thrombotic administration are benign prostatic hyperplasia, haemorrhagic cystitis, renal calculi, renal infarction, infection, and adult polycystic kidney disease. Haematuria only after anti-thrombotic administration can be the presentation of a bladder tumour. Here, 71 years old male patient, with a bladder tumour was reported, who presented with haematuria only after he took dual anti-platelet drugs (tablet Ecosprin and tablet Clopidogrel). He took these drugs after he underwent the insertion of cardiac stents. He never had any previous history of haematuria. After the complaint, ultrasonography was performed and it reported a normal urinary system. So, the anti-platelet drugs were suspected to be the cause of haematuria. Tablet Clopidogrel was stopped and patient was sent home on Tablet Ecosprin. However, one month later, he again developed haematuria. Repeat imaging studies (ultrasonography and computed tomography) detected a urinary bladder mass. Transurethral resection of the mass was performed and a biopsy reported high-grade, muscle-invasive transitional cell carcinoma. This case highlights the fact that all cases of haematuria, irrespective of anti-thrombotic agents’ administration, should be suspected to be due to urological malignancy and the patients should undergo complete urological investigations, including cystoscopy.
Anti-thrombotic agents, Cystoscopy, Ultrasonography, Urological investigation
A 71-year-old male patient, underwent cardiac stenting in July 2019 and he was started on anti-platelet agents (Tablet Ecosprin 75 mg and Tablet Clopidogrel 75 mg). He developed haematuria in January 2020 for which he was admitted to a local hospital for evaluation. He was started on urinary bladder irrigation because of profuse bleeding. Ultrasonography reported normal kidneys, normal bladder, and prostate. The haematuria subsided with bladder irrigation. Since, the ultrasonography did not detect any abnormality in the urinary tract, the haematuria was thought to be due to the effect of the anti-platelet agents. So, a cardiologist was consulted, Tablet Clopidogrel was stopped and the patient was discharged home on Tablet Ecosprin.
However, one month after discharge, he again developed haematuria. So, he was re-admitted and ultrasonography was repeated. The repeat ultrasonography detected a polypoidal hypoechoic mass, measuring 2.8×2.0 cm, with internal vascularity on the left lateral wall of the urinary bladder. Computed tomography was then performed which showed a heterogenous growth of the same size on the left lateral wall of the urinary bladder with perivesical fat stranding (Table/Fig 1).
The bladder tumour was resected on the 9th of March 2020. Biopsy was reported as high-grade urothelial carcinoma with muscle invasion, clinical staging of T3NoMo (1). Since, the bladder growth involved the left lateral wall, he was not suitable for partial cystectomy (2). So radical cystectomy with ileal conduit was planned but the patient refused the proposed operation. He was then lost to follow-up.
Anti-thrombotic agents are used for the treatment and prevention of cardiovascular diseases. The most common anti-thrombotic agents are heparin or its derivatives, vitamin K antagonists and anti-platelet agents, including aspirin and clopidogrel. The most important side-effect of anti-thrombotic agents is bleeding and 2-24% of patients on anti-coagulants develop bleeding complications [3,4]. The bleeding involves the intracranial, gastro-intestinal tract, visceral, musculo-skeletal, soft tissues or urinary tract (5). The overall risks of haematuria in patients on anti-coagulants and anti-platelet agents are 26.7% and 0.5%, respectively (6).
This patient developed gross haematuria only after anti-platelet drugs were administered. The initial ultrasound examination might have missed the bladder tumour due to blood clots in the urinary bladder or sub-optimally distended urinary bladder, as the patient was on bladder irrigation due to haematuria.
In a pooled meta-analysis of 175000 patients who developed haematuria after anti-thrombotic agents’ administration, Bhatt NR et al., reported that urologic pathology in 44% of cases and malignancy was seen in 24% of patients (6). Yu HT et al., reported that oral anti-coagulation therapy-enhanced haematuria in patients with atrial fibrillation, helped to detect bladder tumour earlier and the tumours were low pathologic grade (7). Wallis CJD et al., reported that the use of anti-thrombotic medications caused an increased rate of haematuria-related complications and clinically silent bladder
cancers may be found by the use of anti-thrombotic agents (8). In a study of 227 patients with bladder cancer, Moschini M et al., reported that patients who received anti-platelet or anti-coagulant therapy presented with haematuria significantly earlier resulting in earlier diagnosis and treatment of bladder cancer (9).
This case report underlines the fact that all patients with haematuria, even if the patient is on anti-platelet medication, should be suspected to have urological pathology.
A complete urological investigation should be performed in all cases of haematuria, irrespective of anti-thrombotic administration. As seen in this patient, in cases of recurrent or persistent haematuria, though the initial urological investigations may be normal, repeat investigations should be performed so as not to miss any urological tumour. Cystoscopy should be performed to rule out urinary bladder tumours.
DOI: 10.7860/JCDR/2023/60500.17929
Date of Submission: Oct 06, 2022
Date of Peer Review: Feb 07, 2023
Date of Acceptance: Mar 28, 2023
Date of Publishing: May 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 07, 2022
• Manual Googling: Feb 11, 2023
• iThenticate Software: Mar 27, 2023 (1%)
ETYMOLOGY: Author Origin
- Emerging Sources Citation Index (Web of Science, thomsonreuters)
- Index Copernicus ICV 2017: 134.54
- Academic Search Complete Database
- Directory of Open Access Journals (DOAJ)
- Embase
- EBSCOhost
- Google Scholar
- HINARI Access to Research in Health Programme
- Indian Science Abstracts (ISA)
- Journal seek Database
- Popline (reproductive health literature)
- www.omnimedicalsearch.com