Of the top ten questions I have gotten over the years about misconceptions/misunderstandings of the various treatment of prostate cancer-the concept of the delayed effect of radiation on one’s body is one of the more common.
The typical situation will be the guy who has either had seeds or external radiation. He may have had a little bit of a bumpy go of it early on in the radiation, maybe some urinary symptoms of frequency or urgency or mild self-limited diarrhea, but then did well. That is until about 2-5 years later when he notes blood in his urine or exacerbation of the urinary symptoms again.
In the case of blood that is now visible in the urine and often times associated with clots, I’ll mention to the patient and the wife that his is probably an effect of the radiation and the expected come back is, “But he had radiation five years ago.”
I’ll come back to my thoughts on that but first a note about clots because this is another thing that patients have trouble grasping and something I hear very frequently. Patients will spend an inordinate amount of time explaining clots, the color, how it felt to come out, what it looked like and so forth. This is because they feel that a clot makes the bleeding more significant. The truth of the mater is that a clot is simply blood that settled in the posterior aspect of the bladder then formed a clot. When the clot is voiding out it is compressed into “worm form” as it goes through the prostate and urethra. If you can void at all i.e. no obstructive problem because of the clot then it has no real clinical significance.
“I noticed blood at the tip of my penis after I pee’d red blood. And then a maroon looking gelatin thing came out shaped like a worm, a bunch of them, then there was more blood at the tip of my penis. Ever since then the color of my urine has been blood-red.”
- You rarely lose enough blood in the urine to affect the blood count (it won’t make you anemic.)
- Clots are the result of blood doing what it does, clot, and are molded like my old Mattel worm maker when I was young.
- Think of a clot as a bouillon cube swishing around in the bladder discoloring the urine until it is gone. This is why a patient will say they had blood in the urine, passed a clot and then the urine cleared. The bleeding from the prostate or bladder as a result of the radiation probably stopped hours or days ago. So no active bleeding just the bouillon effect of the clot coloring the urine by dissolving slowly.
- People on blood thinners, including low dose aspirin, are more at risk of bleeding secondary to the effect of radiation.
Radiation cystitis and for that matter radiation urethritis of the prostatic urethra is a given consequence of radiation. It is not a given however if a particular patient will have any symptoms related to it. The symptoms and clinical issues:
- With seeds the vessels along the course of the inner channel of the prostate (the prostatic urethra) become very engorged and the vascularity of blood vessels increase. Visually they look like dilated vessels on a person’s nose if they have that disorder that Jimmy Durante had. In turn they become friable and easy to bleed.
- Radiation cystitis is a term for the same process of the bladder mucosa. The normal vascularity of the inner lining of the bladder becomes more reddened, the vessels more prominent. In some cases the vessels in one spot change and in other patients the whole bladder is involved.
- It usually progresses with time and is more common a year or two out rather than immediately.
- This is why in my book I say “Do you want to pay me now…the immediate issues related to a prostatectomy” or ” Do you want to pay me later-the delayed side effects of radiation.”
What are some of the treatments or management of blood in the face of a past history of prostate cancer and radiation?
- If the patient is on coumadin or aspirin and okay with the cardiologist it is best to stop those.
- The hope is that it is one vessel and that stopping the meds and increased hydration that it stops on its own. This is a common scenario.
- If the patient continues to have blood in the urine with or without clots, for the short-term as long as voiding is possible and no problems with being unable to empty the bladder, it is best in this case as well to pee patient, I mean be patient-ha. You can wait up to 7- 10 days if necessary. Again it usually have very little effect on the hemoglobin.
- Bleeding, with clots and difficulty voiding is a bad case scenario because now the urologist has to do something to get the clots out, place a catheter and get things flowing again. He may or may not have to be fulgurated or treat a bleeding vessel which is the culprit.
- Here’s how it plays out. The patient had seeds three years ago. He notices some blood in the urine. He calls his urologist-note he calls the urologist not the radiation oncologist and is advised to stop any blood thinners, increase water intake and be seen that day or the next. The patient begins passing clots and then in time he can’t void at all “clot urinary retention.” This occurs right after the doctor’s office closes. He calls the operator at the hospital who contacts the urologist and is advised to go to the emergency room.
- By the time the patient gets to the ER he is in near excruciating pain because of the inability to urinate. The clots have clotted off the opening from the bladder to the prostate and as a result urine cannot flow.
- There is a wait to get into a room at the ER however once in the room an IV is started and an attempt probably by one of the ER nursing staff who is good at putting catheters in.
- If the patient has had a prostatectomy and then the radiation, there may be a narrowing at the bladder neck area, the area of the anastomosis, and this will not let the catheter get by and hence after several attempts and meeting no success, the patient may be given pain meds and the urologist is called and told ” We can’t get a catheter in. You need to come.”
- If the nurse is able to get a catheter in then the clots are attempted to be irrigated free so that urine can flow into the catheter and in turn relieve the patient. What normally happens is the irrigation of clots and release of urine and hence relief for the patient is piecemeal. By that I mean that a little urine will come out and then the clot obstructs the foley catheter. The nurse then irrigates the catheter in hopes to retrieve more clot and re-establish urine flow. This may or may not happen as you can’t irrigate as well through a pliable tube such as a catheter as it collapses on itself and thwarts the process. Over time with the suction of clots, irrigation of the clots and often times having to take out a catheter filled with clot that won’t irrigate and reinserting another one hopes to achieve a free-flowing catheter with clots.
- At this point if not already having done so, a three-way catheter is placed so there can be continuous irrigation of fluid to prevent the catheter from getting obstructed and prevent the formation of more clots hence restarting the whole process.
- If a catheter can’t be passed or if catheter keeps being obstructed by clots then the patient often times is taken to the operating room by the urologist and under anesthesia places a rigid cystoscope that is of larger diameter than the catheter and doesn’t collapse on itself, to irrigate out all the clots, stop the bleeding point and then placing the largest three-way catheter as possible.
- All the while this is a very painful drawn out process that can be associated with bladder spasms which have been alluded to many times on this site.
- In time if the clots are all out, the bleeding stopped, the catheter can be removed after a few days and things then go back to normal. The patient still has radiation cystitis, is still at risk for bleeding in the future and if lucky the degree of cystitis stabilizes. It will not go away, but it may quieted down a bit and not progress.
- Now there are things the surgeon did not mention if you had a robotic prostatectomy for sure…but I can see now the brochure and the ads on the internet of the radiation guy playing golf “a few days after the procedure.”
- As I say in the book, “There ain’t no free ride.”
More on this later ….think hyperbaric O2 treatments.