PEEING BLOOD! (Blood in Urine)
Imagine a situation, looming threat of coronavirus infection, people with cough sitting in emergency department and amongst them a 67 years old gentleman scared, not only because of the corona threat but because he was passing frank blood and the blood clots in his urine! Mr AP had never experienced so much of blood in the toilet, all over on the floor before and had no option but to rush to the hospital. He was in pain as he wasn’t able to pee now. I have seen and treated many such patients in UK, Australia but this was my first one since I started my practice here in India. From my extensive experience in dealing with such cases I knew exactly the gravity of this situation hence when the hospital approached me, without wasting anytime I left for the hospital.
Whilst on my way to the hospital I had instructed the staff and the RMO on duty to arrange a catheter (tube for Urine), start him on fluids through his vein, monitor his pulse and blood pressure, send bloods for looking at his haemoglobin and kidney functions as well as blood clotting study. I also advised them to arrange at least 2-3 units of blood in case he requires blood transfusion. The RMO attempted putting catheter, but she wasn’t able to in Mr AP’s case. She found the catherization to be difficulty despite her experience in putting catheters in patients. These type of emergencies and situations are very critical, and one has to act systematically as well as promptly considering the nature of the emergency. I found the nurses and the RMO to be efficient as things were kept ready for me as I entered the emergency bay where Mr AP was.
Mr AP was relieved to see me as he now had a confidence that he would be relieved from his problems. The RMO and nurses had already told him about me. After a quick look at his blood pressure and the pulse rate and making sure that he is in stable condition, whilst going through his problems along with explaining what I was doing, I inserted something called a three-way catheter in his bladder. It is a rubber tube that is inserted in the bladder through the water pipe (urethra) to relieve blockage of urine called retention of urine and sometimes to monitor as to how much urine patient is producing. Catheters can be 2 way or three way. In 2-way catheter one channel is for urine and the other is for a balloon which keeps catheter in place. In 3-way catheter third channel is to put fluid inside the bladder to wash the bladder out, which is mainly used by urologists. I have performed several thousands of successful catheterisations in patients in India as well as in UK and Australia.
Once I successfully catheterised Mr AP, almost 400 ml of blood mixed urine with some clots came out. Mr AP was immediately relieved of his pain and retention. I then performed a procedure called bladder washout where a sterile saline water is used for manually washing out the blood and blood clots from the bladder. This is a very important step as, if a urologist do not remove all the clots from the bladder, the catheter can get blocked, bleeding can restart and patient can go back in to retention with severe pain and discomfort. This may lead to need for change of catheter which not only is traumatic for the patient but also can lead to infections. After making sure that his urine was clear on washout, I started him on continuous bladder irrigation where from one channel saline goes in and comes out from other channel continuously washing the bladder and prevention any further bleeding as well as blockage. Once I made sure that his urine was now clear, and he was in absolutely stable condition, I began a detailed history taking.
Mr AP had urinary symptoms of urgency for urine. He was often having to pass urine during the day and was waking up at night also. 20%-30%of bladder cancer patients may present with these type of irritable bladder symptoms hence it becomes imperative to do cystoscopy (camera in the bladder) for patients presenting with irritable bladder symptoms. Mr AP was also a chronic smoker and had smoked since age of 25 years. Unfortunately, smoking is one of the major risk factors for development of a bladder cancer as well as kidney cancer. Mr AP had no other medical problems except well controlled hypertension (raised blood pressure). His blood tests were all normal including stable haemoglobin and normal clotting study. His Covid-19 test was also negative. I reassured him about the bleeding. I admitted him in the hospital to carry out continuous bladder irrigation (washing of bladder from inside). Next day after my morning review he started bleeding again……
One option was to continue with washing the bladder to see whether it stops (which does work lot of the time) and once bleeding stops then do a cystoscopy (telescopic examination of bladder) to find out and sort out the reason for bleeding. Second option was to perform emergency cystoscopy to find out and control the bleeding. This option is also advisable in case of severe bleeding, significant drop in haemoglobin or drop in blood pressure (patient going in shock). On discussing the options with him he was very keen for me to operate on him as he wanted solution of the problem straight way as well as wanted to know the reason for bleeding. It has always been my practice that I do not pressurise patients to have something done neither I push myself onto the patients. I always have thorough discussion with patients and their relatives if patient wants me to discuss with the family member or a relative, I inform them the risks and benefits of all the available options and help them making the right decision. I take decisions by involving g patient in the decision making, allow them to make informed decision and I answer all their questions to their full satisfaction. Mr AP wasn’t an exception for that. When I saw him, he had dropped his blood pressure too, which I corrected by giving fluids through his vein, but this was another reason why I needed to look inside his bladder on emergency basis.
I also organised CT scan of his urinary system (kidney, ureters and bladder) with contrast (dye is injected in the blood) to make sure that his kidneys and ureters did not have anything sinister in them. Anyone presenting with visible blood in the urine, even if single episode, as per my evidence-based practice, British, European and American guidelines I organise CT Urogram (scan of urinary system) and camera test of the bladder called cystoscopy. This is to make sure that there are no sinister causes like cancer causing blood in the urine. There are some other tests like urine cytology (looking for cancer cells in urine) and tumour markers in urine are done for investigation purpose. His CT scan showed normal kidneys and ureters and bladder. Neither CT scan nor a sonography (ultrasound scan) are reliable tests for bladder cancer. Neither of them can replace cystoscopy and you would understand later why I am saying this.
I was somewhat certain that he may have a bladder cancer, but I wasn’t sure as to what I was going to find out inside his bladder. If there is a bladder cancer, then what would it be and its extent. I had blood units on standby in case he requires blood transfusion. Upon entering into his bladder there was a bladder cancer as expected. This was not seen on CT scan. This is the reason why patients require cystoscopy along with scan. Luckily it was a small cancer which looked superficial but had bleeding area inside. I performed a procedure called TURBT (transurethral resection of bladder tumour) on him. In this procedure bladder cancer is cut and removed from inside the bladder without making any cuts on the skin. Post operation I gave him dose of chemotherapy medication called Mitomycin C inside his bladder which reduces the chances of cancer coming back by 39%.
Next day morning I removed the urinary catheter of Mr AP and discharged him home. His urine was clear, and he had no further blood in his urine. Before his discharge, I had a meeting with him and his family members (with his consent) about the operative findings and the procedure I was required to carry out on him. Even though Mr AP and his family were upset with the news of possible cancer they were relieved that I had removed it completely. I explained them that depending the histopathology report I would decide his further management. I counselled Mr AP to give up smoking, which he promised to do so. Histology report confirmed that it was superficial bladder cancer (Grade was G1pTa). Due to Covid-19, I carried out online follow up with him and explained him the histology result, which I had already prepared him for. I explained the need for a regular cystoscopy as a follow up even though he was cured from his cancer.
Mr AP was at least lucky that bladder cancer presented with blood in urine in his case but in some people, it may not be the case. The cancer may present with urine symptoms typical of irritable bladder. In some people it may present with non-visible (urine looks normal in colour) bleeding which gets picked only on urine test. Hence if urine tests done for any other purpose shows microscopic blood in it, please seek urologist opinion as there is 5-9% chance of bladder cancer to be there in presence of nonvisible or microscopic blood in urine. Please don’t ignore it as ignorance could have a devastating consequence. In developed countries like UK, Australia, US there are guidelines in place whereby their GPs have to refer the patients with blood in urine (visible or nonvisible) to the urologist. Unfortunately, we don’t have such guidelines neither awareness. I am currently working on the aspect of creating awareness amongst people about this deadly cancer.
Every year nearly 500000 people get diagnosed with bladder cancer and nearly 200,000 people die due to the bladder cancer. India has worst survival rate of bladder cancer making it one of the deadliest cancers. Unfortunately, in India there is lack of awareness about the bladder cancer amongst common people as well as medical practitioners hence the diagnosis and investigations for the bladder cancer are not adequate. It has the highest lifetime treatment costs per patient of all cancers and causes huge economical loss in billions of dollars per year. It is 6th most common cancer in India and 6th most cause of cancer related deaths. Fifteen percent of all tobacco-related cancers are bladder cancers. India has second highest number of deaths rate after china, due to bladder cancer (59,041) amongst Asian countries. Delayed diagnosis of bladder cancer, inadequate and incorrect, or sub optimum treatment are the chief factors that cause poor bladder cancer survival in India. Metastatic bladder cancer (cancer spread to other organs) has poor prognosis as only 8% patient survive up to 2 years. This cancer can only be defeated by early detection and early treatment as survival rate is more than 80% if caught early.
It is my sincere request to all the people and all the medical practitioners not to ignore even a single episode of blood in urine, not to ignore microscopic blood in urine on urine test as BLADDER CANCER could be hidden inside. We need to catch it early and destroy it for our life and happiness as well as happiness of our loved ones.
• Do not ignore even a single episode of visible blood in urine at any age. Do not ignore pink, red or rusty/brown coloured urine even on one occasion.
• Do not ignore if your urine on test shows microscopic blood or blood cells
• General practitioners, physicians and all other faculties, please refer any patient with visible or nonvisible blood in urine to the urologist to rule out possibility of bladder cancer.
• Smoking is the main cause for bladder cancer hence stop smoking or give up smoking. It is for your own health and for your loved ones as smoking kills with bladder cancer and kidney cancer too.
• If you have been getting recurrent (multiple) urinary infections, seek urologist opinion as there may be underlying bladder cancer.
• If you have been going to pass urine more often than normal (increased frequency) or you get urgency to pass urine, see your urologist as they may be sign of bladder cancer.
• If you have Bladder cancer in your family, then do not ignore any of above symptoms.
• Sometimes chronic bladder inflammation with bladder stones, urinary catheter also can cause bladder cancer.