CASE REPORT

Endoscopic treatment of massive rectal bleeding following transrectalultrasound-guided prostate biopsy

ENRIQUE PACIOS1, JOSE MIGUEL ESTEBAN2, MARIA LUISA BRETON1,

MIGUEL ANGEL ALONSO3, JUAN JOSE SICILIA-URBAN1 & MARIA PILAR FIDALGO1

Department of 1Emergency Medicine, 2Endoscopy and 3Urology, Hospital Clınico San Carlos, Madrid, Spain

AbstractRectal bleeding is frequently seen in patients undergoing transrectal ultrasound-guided prostate biopsy. This report details acase of life-threatening rectal bleeding following this procedure which was successfully treated by means of endoscopicsclerotherapy. The aim of this report is to share our experience of the management of massive rectal bleeding followingprostate biopsy.

Key Words: Biopsy, prostate, rectal bleeding, endoscopy

Case report

A 56-year-old male presented to our emergency

department complaining of rectal bleeding and a

feeling of light-headedness. His medical history

revealed arterial hypertension and atrial fibrillation.

He was taking telmisartan and an oral anticoagulant.

He had undergone a transrectal ultrasound (TRUS)-

guided prostatic biopsy 48 h before, and previously

unfractionated heparin had been given in place of

the oral anticoagulant. He had been discharged 24 h

later after administration of subcutaneous enoxa-

parin and oral telmisartan. On physical examination

the patient was found to be stable and diaphoretic.

His abdomen was soft, with no suprapubic tender-

ness. Severe rectal bleeding continued; 1 h later he

became unstable and his blood pressure was 80/50

mmHg. After stabilization, an emergency colono-

scopy was performed; this revealed a lesion in the

anterior rectal wall 5 cm from the anal verge with

active bleeding (Figure 1). Endoscopic treatment

was performed with an initial injection of 10 cm3 of

adrenaline into the submucosa, followed by a second

injection of 2 cm3 of pure ethanol. The bleeding

stopped (Figure 2). The patient needed two units of

blood as his haemoglobin level had dropped from

15.6 to 11.6 g/dl.

Discussion

TRUS-guided prostatic biopsy is associated with low

morbidity and mortality [1�4]. The incidence of

rectal bleeding is variable (1.3�59%) [1,2]; however,

the incidence of significant (moderate to severe or

massive) rectal bleeding can be as high as 8.2%

[5�7]. Patients with severe, massive or life-threaten-

ing rectal bleeding have hypovolaemic symptoms

that tend to occur shortly after the procedure, or a

few days later [5,7�10]. At the Department of

Urology of our hospital, :/800 prostate biopsies

are performed annually. Between October 2002 and

December 2005, three patients were treated for

massive rectal bleeding following prostatic biopsy,

indicating an incidence rate of 0.1%. The first

patient needed a blood transfusion, as reported

herein. With regard to the second patient, endo-

scopic haemostasis was necessary for persistent

bleeding in spite of treatment with haemostatic

gelatin foam and digitally applied rectal pressure.

In these two cases, sclerotherapy was done by means

of injection of adrenaline (1/10 000) and pure

ethanol. In the third patient, haemostasis treatment

was carried out using balloon tamponade with an

inflated Foley catheter. In spite of this treatment, a

colonoscopy revealed local haemostasis after an

Correspondence: Enrique Pacios, MD, PhD, San Mateo 2, 3-B, 28004 Madrid, Spain. Tel: �/34 91 531 0413. Fax: �/34 91 559 0229. E-mail:

koryth@telefonica.net

Scandinavian Journal of Urology and Nephrology, 2007; 41: 561�562

(Received 29 August 2006; accepted 23 October 2006)

ISSN 0036-5599 print/ISSN 1651-2065 online # 2007 Taylor & Francis

DOI: 10.1080/00365590601116832

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adherent clot appeared which could not be elimi-

nated with water. We found 14 reported cases

[4�11] of massive rectal bleeding following needle

biopsy of the prostate. Many techniques have been

used to stop this massive rectal bleeding. Local

manoeuvres (digitally applied rectal pressure or

haemostatic tamponade) over the prostate failed to

stop the bleeding [4,5,7,8]. Balloon tamponade

using an inflated Foley catheter placed in the rectum

has been shown to be efficient in two-thirds of

patients [4,6,11]. In two reported cases bleeding

was successfully controlled, one using a condom

balloon tamponade technique [8] and the other with

a rubber band [7].

In summary, massive rectal bleeding after

TRUS-guided prostate biopsy is an uncommon

complication. Because local manoeuvring fails to

stop bleeding in most patients and other techniques

(balloon tamponade and rubber band) are bother-

some, colonoscopy allows for diagnosis and therapy

of massive rectal bleeding following prostate biopsy.

Acknowledgements

We thank Ms Nuria Gonzalez for proofreading the

manuscript.

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Figure 1. Active bleeding in the anterior rectal wall at the location

of the biopsy. The yellow arrow shows the point from where the

blood oozes.

Figure 2. Endoscopic image after sclerotherapy with noradrena-

line plus pure ethanol. Partial healing of the lesion can be

observed.

562 E. Pacios et al.

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