The effect of oral anticoagulation on the prevalence and management of haematuria in a contemporary Australian patient cohort
Authors: Satasivam Prassannah , Reeves Fairleigh , Lin Matthew , Daruwalla Jurstine , Casan Joshua , Lim Chan , Royce Peter L. 
Published: November 2012

What's known on the subject? and What does the study add?

Urologists are increasingly involved in the management of patients taking oral anticoagulation (OA) who present with haematuria. It is accepted practice that haematuria in the presence of concurrent anticoagulation requires a full diagnostic evaluation, as it is frequently precipitated by a significant pathological lesion. However, there is limited data on the impact of anticoagulation on the initial inpatient management of these patients. Much of the current evidence is either based around perioperative management of elective patients or, for emergency presentations, is focused on bleeding associated with high morbidity and mortality, such as in the neurosurgical population.

In the present study, about half of all admissions with haematuria were for patients on some form of OA. The use of OA strongly predicted for the need for admission for bladder irrigation, regardless of the type of agent or combination of agents used. The use of dual antiplatelet therapy had the strongest association with the need for bladder irrigation, probably due to the well‐described synergistic effect between aspirin and clopidogrel. The results of the present study emphasise the importance of early intervention in the management of patients on OA presenting with haematuria.

Objective

To examine the effect of oral anticoagulation (OA) on the prevalence  and inpatient management of haematuria in a contemporary Australian patient cohort.

Patients and methods

Patients across all inpatient units who had diagnosis‐related group (DRG) coding for haematuria were identified from April 2010 to September 2011.

A retrospective chart review was performed to identify the type of anticoagulation (if any), requirement for bladder irrigation or blood transfusion, length of stay (LOS) and cause of haematuria.

Patients for whom the anticoagulation status was uncertain were excluded from analysis.

Statistical significance was determined by Pearson's chi‐square tests and Student's t‐tests.

Results

In all, 335 admissions with DRG coding for haematuria were identified from hospital records, of which 268 admissions had clear documentation of anticoagulation. There were 118 emergency admissions and 150 elective admissions for day case cystoscopy. The mean age of the patients was 66 years and the male:female ratio was 5:1. In all, 123 admissions were for patients on some form of anticoagulation (46%).

Patients were on anticoagulation in 53% of the 118 emergency admissions for gross haematuria. These comprised patients on aspirin (28%), clopidogrel (4%), warfarin (10%), combined aspirin and warfarin (1%) and combined aspirin and clopidogrel (10%).

The use of OA was a significant predictor of the need for intervention among the  118 emergency admissions (86% vs 62%,  P = 0.003).

In particular, dual antiplatelet therapy in the form of aspirin and clopidogrel was associated with an increased requirement for bladder irrigation (92%) when compared with patients on other forms of anticoagulation (84%) or none at all (62%, P = 0.01).

The mean LOS for patients admitted to hospital with haematuria was 5.6 days. Patients on warfarin had a statistically significant longer LOS than the other groups (13.7 vs 4.5 days, P < 0.001). A cause for haematuria was identified in 120 of the 234 patients (51%). Of these, the most common was benign prostatic hyperplasia (21%), followed by bladder urothelial carcinoma (17%).

Conclusion

In our cohort of patients, about half of all admissions with haematuria were for patients on some form of OA.

OA use increased the need for intervention, especially for patients on dual antiplatelet therapy.