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Seeing red after a prostate procedure
  1. Maximillian Hugo Brodermann,
  2. Mark A Samaan,
  3. Shameer Mehta,
  4. Sara McCartney
  1. Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
  1. Correspondence to Dr Sara McCartney, Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK; sara.mccartney{at}nhs.net

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Clinical presentation

A 71-year-old man attended accident and emergency with a 1-day history of rectal bleeding without associated abdominal pain, change in bowel habit or history of GI disease. On admission, his haemoglobin was normal at 147 g/L with normal platelets of 194×109/L. There was a raised white blood cell count of 12.2×109/L (normal range 4.5−11×109/L) and normal C-reactive protein of 2.2 mg/L. His urea and electrolytes and liver function tests were normal. The patient had no recent changes to his regular medication and did not take non-steroidal anti-inflammatory drugs, antiplatelet or anticoagulant medications. He reported feeling well with no fevers or weight loss and denied any previous similar episodes. He had recently undergone a minimally invasive procedure for benign prostatic hypertrophy (BPH) with no intraprocedural complications.

A same-day flexible sigmoidoscopy was performed which revealed four shallow rectal ulcers up to 2 cm in diameter. A small amount of fresh red blood was seen but there was no evidence of active bleeding or other endoscopic abnormalities up to the descending colon. An example of the rectal ulceration is shown in figure 1.

Figure 1

An example of the ulceration observed in the rectosigmoid region. The ulcers were superficial, well-demarcated, had a pale central region with haemorrhagic penumbra and were separated by endoscopically normal mucosa.

Question

What is the cause of bleeding and how should this patient be managed?

Answer

This patient had rectal ulceration as a complication of bilateral prostatic artery embolisation (PAE). PAE is an alternative to transurethral resection of the prostate for BPH that achieves similar improvement in lower urinary tract symptoms and is safer in higher-risk surgical candidates.1 Limited data suggest that 2.4%–27% of patients undergoing the procedure experience rectal bleeding.2 3 The mechanism by which PAE may result in ischaemic proctopathy is due to the prostate gland’s arterial supply anastomosing with branches of the rectal arteries in 29% of individuals.4 Variabilities in the prostate gland’s arterial supply are characterised by angiography prior to embolisation, as illustrated in figure 2. Urinary tract symptoms are more common adverse effects than rectal bleeding, but gastroenterologists should also be aware that diarrhoea is reported in up to 18%.2

Figure 2

Angiography to confirm the patient’s prostatic arterial supply prior to embolisation with 250 and 400 µm polyvinyl alcohol particles.

On reviewing the literature, we identified a single case report of endoscopically confirmed transient ischaemic proctopathy as a cause of rectal bleeding post PAE.5 In this individual, rectal ulceration was observed at day 4. The patient was managed conservatively and the ulcers resolved by day 16.5 In keeping with the previous case, our patient was managed conservatively and his symptoms resolved a day after the presentation. He had experienced no recurrence of GI symptoms by the time of follow-up, which is 6 weeks later. Therefore, no further endoscopic investigation was deemed necessary. Biopsy samples were not taken at the time of the index endoscopy in view of the potential risk of fistulation and high likelihood of the ulcers being ischaemic in nature based on the clinical history and endoscopic appearances. We recommend a similar approach in stable patients with small volume and self-limiting bleeding following PAE.

References

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Footnotes

  • Contributors MHB and MAS drafted the manuscript, which SM and SMc reviewed for important intellectual content. All the authors reviewed and edited the final article.

  • Competing interests MHB: None. MAS: Advisory fees: Takeda, Janssen and Falk. Lecture fees: Takeda, MSD, Janssen and Falk. SM: None. SMc: Advisory fees: Abbvie and MSD.

  • Patient consent for publication Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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