Anticoagulants and bleeding in urology

Clinical relevance

• Increasing numbers of patients take anticoagulants and antiplatelet agents.
• These drugs increase bleeding risk during urological procedures and after trauma.

Drugs

• Antiplatelet agents: aspirin, clopidogrel, ticagrelor.
• Anticoagulants: warfarin, heparin, low-molecular-weight heparins, rivaroxaban, apixaban, dabigatran, edoxaban.

Clinical assessment

• History: drug, dose, time of the last dose, indication.
• Signs of bleeding: hematuria, hematoma, clot retention, falling Hb, hypotension.

Emergency management

• In life-threatening bleeding, stop the anticoagulant immediately, achieve hemostasis, and select reversal according to the specific drug, time of the last dose, kidney function, and antidote availability.
• In clinically significant but non-life-threatening bleeding, assess the need for temporary interruption, local hemostasis, laboratory monitoring, and consultation with the relevant specialist.
• In gross hematuria, assess hemodynamics, hemoglobin, urinary drainage, and the cause of bleeding; the absence of clot retention does not rule out a need for active hemostasis or reversal.

Drug-specific reversal

• Warfarin: in life-threatening bleeding, give 4-factor prothrombin complex concentrate together with intravenous vitamin K; use fresh frozen plasma if PCC is unavailable, according to the local protocol.
• Dabigatran: idarucizumab 5 g intravenously when indicated; consider the time of the last dose and kidney function.
• Apixaban, rivaroxaban, edoxaban: an approved and available specific antidote or 4-factor PCC according to the local protocol. Assess the last dose and kidney function.
• Unfractionated heparin: protamine according to the dose of recently administered heparin. Low-molecular-weight heparin: protamine provides partial reversal; the regimen depends on the drug and time of the last dose.
• After hemostasis, document the indication for anticoagulation and the plan for resumption. Unjustifiably prolonged interruption increases thrombosis risk.

Algorithm