The document discusses various treatment options for managing hematuria, including intravesical alum irrigation, formalin, hydrostatic pressure, embolization, hyperbaric oxygen therapy, and sodium pentosanpolysulphate. Each method is detailed with protocols, side effects, and success rates, emphasizing the importance of specific preparations and monitoring during procedures. Overall, the document provides a comprehensive overview of the strategies for addressing intractable hematuria in clinical practice.

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.