Use of foley balloon tamponade in transrectal prostate biopsy hemorrhage

published in the December issue (vol. 30, pages 541545, 1987), J. P Chapman et al. imply that the degree of hydronephrosis equates with the degree of obstruction. This is a common trap into which both urologists and radiologists fall all too frequently. It is well known from ultrasound and urographic studies that the degree of dilatation of the urinary tract varies greatly in acute ureteral obstruction. In the first few hours of even complete obstruction, minimal or absent pelvicalicectasis is common, whether or not there is extravasation. The degree of dilatation (pelvicalicectasis, hydronephrosis) should never be equated with the degree of obstruction. To underscore the point, one only has to consider the example of massive reflux causing nonobstructive pelvicalicectasis. The Journal should encourage proper use of these terms. I also take issue with several other points in the article. The authors claim that men are more likely to extravasate than women, but we are not given the data necessary to determine if this is the case. We would need to know what percentage of women with acute ureteral obstruction have extravasation compared with men. Stones are much more common in men. Furthermore, since 80 to 90 percent of small UVJ stones pass spontaneously regardless of the presence or absence of extravasation, the authors are not justified in attributing stone passage to resumption of peristalsis related to extravasation. Stone size and location seem to be overriding factors. Finally the authors call their study prospective; it seems retrospective to me. Lee B. Tamer, M.D. Chief, Diagnostic Radiology University of California

Medical Center, San Diego 225 Dickinson Street San Diego, California 92103-1990

USE OF FOLEY BALLOON TAMPONADE IN TRANSRECTAL PROSTATE BIOPSY HEMORRHAGE To the Editor: The transrectal prostate biopsy is one of the most commonly performed urologic procedures. Indeed, many urologists now perform transrectal biopsies on an outpatient basis in an office setting. The principal complication of this procedure, aside from sepsis, is rectal hemorrhage from vessels or traumatized mucosa above the anal

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sphincter. Transanal hemorrhage then occurs intermittently whenever the rectal ampulla fills with enough blood to stimulate the urge to evacuate. The amount of rectal bleeding may be severe enough to warrant blood transfusions and surgical intervention. Many techniques have been used to stop the rectal bleeding. Parenteral analgesia is often the first measure applied. However, the relative hypotension obtained through parenteral injections usually does not stop severe hemorrhage. The second method often utilized is direct rectal packing with a roll of Kerlex or cling gauze. This may be left in place for a few hours and removed slowly after the bleeding has abated. Unfortunately, severe rectal hemorrhage will not stop with packing. We advocate the following technique which should be used as the initial management of all rectal bleeding post-transrectal prostate biopsy: 1. The patient is placed in the supine position and a 30-cc Foley catheter with 45 cc of water in the balloon is placed in the rectum. The Foley catheter is connected to straight drainage. Intravenous antibiotics, preferably ampicillin and gentamicin, are given as an adjunct against sepsis. 2. Mild traction is applied, and the catheter is taped to the inner thigh. The amount of bleeding may be observed by viewing the contents of the drainage bag. 3. The traction is released after forty-five minutes, and the catheter is removed from the rectum. If continued bleeding occurs, direct suture ligation of the bleeding vessel should be performed through an anoscope by one familiar with this approach. Blood is an excellent cathartic. Continued passage of dark blood after the rectal Foley catheter is removed, without change in the vital signs, is probably old blood; more red blood means that the bleeding is on-going. You may receive a call from a frightened patient or nurse who believes that the rectal hemorrhage has begun again. Remember that rectal bleeding is bright red and will occur every fifteen minutes as soon as the rectal ampulla is filled with blood. This melena simply represents old blood that has previously entered the colon in a retrograde manner and is now undergoing transit.

VOLUME XxX11, NUMBER 2

Richard D. Baum, M.D. Michael Slade, M.D. The Valley Hospital Ridgewood, New Jersey 07432

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