Introduction

Transrectal prostate needle biopsy with ultrasound guidance has become the standard for the diagnosis of prostate cancer.¹ Common postprocedural complications including limited hematuria, hematospermia and hematochezia have been reported.² Most studies have low rates of more significant complications such as urinary tract infection, urinary retention and sepsis.^3,4 We report on an unusual case of life-threatening rectal hemorrhage after transrectal prostate biopsy.

Case report

A 64-yr-old African-American man underwent transrectal ultrasonography with 10 cores of prostate tissue sampled from bilateral apices, mid-regions, bases, apical peripheral zones and mid-peripheral zones. A Manan Pro-Mag 2.2™ biopsy gun with an 18 gauge needle was used and no anesthesia was required. He had been prepped with an enema and oral levofloxacin prophylactic antibiotic that morning and received a second antibiotic dose the following morning. He had stopped aspirin 10 days prior to the procedure. He had a past medical history of three drug hypertension and lower urinary tract symptoms attributed to BPH. He had been biopsied eight times in the previous 8 years for persistently rising PSA, 6.6–18.8 ng/dl, with benign digital rectal exam and had at least 64 cores sent for pathologic analysis. During this time-frame, his prostatic volume increased form 49.8 to 69.0 g as measured by ultrasound. He had experienced mild hematochezia with previous biopsy sessions. He had hematospermia up to 6 months duration after prior biopsies. The procedure was well tolerated, but because of rectal bleeding immediately afterwards, digital compression of the prostate was performed with cessation of bleeding. He returned home and had minimal dark red hematochezia with bowel movements for two successive days. He restarted his aspirin on the evening of the procedure. At 5 days after his biopsies, while straining at a bowel movement, he developed bright red hematochezia and immediately went to the emergency room. He had taken no antihypertensives that day. In the emergency room his initial hematocrit was 39% and he continued to have frequent bright red bowel movements. His blood pressure was 181/103 and he demonstrated orthostatic changes by pulse criteria. Anoscopy demonstrated pulsatile bleeding from the anterior rectal wall directly over the prostate. Digital compression and intravenous fluid resuscitation was initiated. Follow-up hematocrit was 26% and he was given 2 U of packed red cells. Coagulation studies were normal. Blood pressure was initially controlled with intravenous labetalol followed by his previous outpatient regimen. After 45 min of digital compression and normalization of blood pressure, the bleeding stopped. Stool softeners were given. Flexible sigmoidoscopy the next day demonstrated an area of erythema over the prostate and no active bleeding. The pathology of his prostate biopsy showed prostate adenocarcinoma in four of 10 cores with a Gleason score of 9. A bone scan and Prostascint™ scan were obtained that showed a metastatic rib lesion and bilateral iliac adenopathy consistent with metastatic prostate cancer.

Discussion

Mild hemorrhagic complications are a common problem after transrectal prostate needle biopsy. Enlund and Varenhorst,⁵ after biopsing 415 men, showed a 22% immediate postbiopsy rate of hematochezia, which then decreased to 3% at 3 days and only 0.5% continued to have hematochezia at 7 days follow-up, no one required hospital admission or transfusion. Hematochezia that requires hospital admission for observation or transfusion is unusual. There have been a few cases of hemorrhage significant enough to warrant transfusion or open surgical procedure, and these have been associated with retropubic hematomas that are attributed to injury of the periprostatic venous complex and inferior vesical and middle rectal arteries.^6,7,8,9 A review of recent MEDLINE English literature studies that report on complications of transrectal prostate biopsies and list hematochezia as a complication, showed that of 5911 men biopsied only four required admission for observation of hematochezia, three had oversewing of the rectal mucosa within 2 h of the biopsy to stop bleeding and none required transfusion (Table 1).^{10,11,12,13,14,15,16,17} This man had an arterial bleeder that opened 5 days after his biopsy; poorly controlled hypertension and the firm bowel movement most likely contributed to the life-threatening hemorrhage. Neovascularization related to his large volume of disease with high Gleason-grade carcinoma may also have contributed to this patient's excessive bleeding. The use of aspirin may have played a role in the bleeding, although several studies have suggested that aspirin use does not significantly increase the risk of hemorrhagic complications.^18,19 A single case of massive anterior rectal wall hematoma after prostate needle biopsy has been reported, and that case was also associated with uncontrolled hypertension and aspirin use.²⁰ We consider that uncontrolled hypertension and constipation may be relative contraindications to prostate needle biopsy and should be corrected prior to the procedure.

Table 1 - Bleeding complications of TRUS guided prostate needle biopsy.

Full table

References

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