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1. HEMATURIA MANAGEMENT
Dr. Vipin Sharma mch 1st yr.
REFERENCES; CAMPBELL - WALSH UROLOGY
THE MANAGEMENT OF INTRACTABLE HEMATURIA ;BUJINTERNATIONAL (2000),86,951-959

2. TREATMENT OPTIONS
• Intravesical alum irrigation.
• Intravesical formalin.
• Hydrostatic pressure.
• Embolization.
• Hyperbaric oxygen for radiation cystitis.
• Sodium pentosanpolysulphate for chronic gross hematuria.
• Intravesical PG for cyclophosphamide-induced hematuria.
• First step— ABC of life support ,clot evacuation.

3. INTRA VESICAL ALUM
• It was first introduced by Floyd Csir in 1982.
• Continuous closed irrigation with a 1% alum solution in
sterile water through three-way foley catheter at bedside,
with no general or regional anaesthesia.
• Aluminium ammonium sulphate or potassium sulphate.
• Astringent action of protein precipitation at the cell surface
leads to
• Decreased Capillary permeability, contraction of
intercellular space,
• Vasoconstriction, hardening of the capillary endothelium
• And a reduction in edema, inflammation and exudate.

4. PROTOCOLS FOR ALUM IRRIGATION
• Using a 1% alum solution
• 50 g of alum is dissolved in 5 L sterile water and used to
irrigate the bladder at 250±30 ml/h.
• other method ; -Using the 1% solution or a stock solution of
400 g of potash of alum (McCarthy's) in 4 L hot sterile water.
• 300 ml of the stock solution is added to 3 L of 0.9% saline
and the bladder irrigated with up to 30 L of this solution in
24 h.

5. SIDE EFFECTS
• Suprapubic discomfort.
• Colloid-like precipitation occurred with slow irrigation.
• Pathological accumulation may occur.
• Toxicity of aluminium causes neurofibrillary degeneration in the CNS
- manifests as
• Encephalopathy, malaise, speech disorder, dementia, convulsions and
vomiting.

6. INTRAVESICAL HELMSTEIN'S HYDROSTATIC
PRESSURE
• Epidural anaesthetic
• Simply filling the bladder with normal saline via a foley
catheter, or by using a balloon attached to a cut foley catheter
through which a steel tube was advanced and specially
designed balloons.
• Used a pressure of 10±20 cm H2O above diastolic pressure
was maintained for 6 hrs.

7. INTRAVESICAL HYDROSTATIC PRESSURE
• Side effects
 Nausea and vomiting.
 Temporary incontinence.
 Severe abdominal pain.
 Pyrexia.
 Bladder rupture.

8. EMBOLIZATION
• Therapeutic embolization was described by Hald in 1984.
• The internal iliac artery was catheterized by puncturing the femoral
or axillary artery
• The internal iliac artery or its anterior division can be embolized with
gel foam.
• The commonest complication is superior gluteal pain & rarely
gangrene of the bladder .
• The success rate is 90 %.

9. INTRAVESICAL FORMALIN SOLUTIONS
• Formalin precipitates cellular proteins of the
Bladder mucosa
• Occluding and fixative actions on telangiectatic tissue and on small
capillaries
• Changes involve edema, inflammation and
Necrosis throughout all layers of the bladder.
Under general or spinal anaesthesia.

10. INTRAVESICAL FORMALIN SOLUTIONS
• Use cystography to exclude reflux
• Evacuate blood clots and coagulate major bleeding vessels.
• Protect all external areas on the skin and mucosa with
Vaseline.
• Irrigate the bladder with a low concentration (1-2%) for 10
min under gravity at <15 cm h2o.
• Monitor the bladder pressure if possible and discontinue the
procedure when the pressure is >50 cmh2o.
• Limit the contact time to 15 min

11. SIDE EFFECTS OF FORMALIN
• When absorbed into the systemic circulation-i converted into formic acid and
formate. Formic acid triggers an inhibition of cholinesterase, succinate oxidation,
anaerobic glycolysis and hexokinase.
COMPLICATIONS OF FORMALIN
• Contracted bladder.
• Urinary incontinence.
• VUR.
• Ureteric strictures.
• Vesico-ureteric junction obstruction
• Acute tubular necrosis.
• Vesicovaginal fistula, vesico-ileal fistula.
• Toxic effect on myocardium.
• Rupture of the bladder

12. PROTOCOL FOR HYPERBARIC OXYGEN THERAPY
• Hyperbaric oxygen therapy causes neovascularization of
bladder wall & increase the oxygen tension in the bladder.
• Therapy use for Radiation cystitis.
• Twenty sessions of 100% oxygen inhalation at 0.3 MPa in a
multiplace hyperbaric chamber (90 min/session).
• Daily sessions five or six times a week sessions may be
increased to 40.
• Decompression sickness may occur rarely.
• Success rate is 75 %.

13. SODIUM PENTOSANPOLYSULPHATE
• 100 mg of oral sodium pentosanpolysulphate three times per
day.
• Time to control bleeding was 4 to7 weeks of therapy.
• Increase the natural defense of the bladder-urine interface
by coating the lining of the bladder, which may have been
damaged by irradiation.

14. CYCLOPHOSPHAMIDE CYSTITIS
• Cyclophosphamide results in acrolein (a hepatic metabolite) being
excreted in the urine.
• causes hemorrhage, edema, ulceration and necrosis of the
urothelium.
• PGE1, E2 and F2a have been used to treat.

15. PROTOCOLS FOR INTRAVESICAL PGs.
• Protocol 1
• Cystoscopy and clot evacuation.
• Instill 50 ml of 4 mg/L carboprost tromethamine in
the bladder and maintain for 1 h.
• Drain the bladder, instill another 50 ml and maintain for 1 h.
• Unclamp the catheter and irrigate the bladder with normal saline.
• Repeat the instillation four times a day.
• The dosage is increased to 10 mg/l.
Protocol 2
• Irrigate the bladder continuously with 8-10 mg/L carboprost tromethamine
at 100 ml/h for 10 h.