Cystoscopy and Warfarin

[Computec]

A little guidance here, please.

I'm scheduled for a cystoscopy this coming Friday. The urologist is a new specialist for me and took my medical history when I saw him. He knows I'm on warfarin. He's scheduled this procedure and made no mention of stopping the warfarin prior to it. Is this an oversight on his part?

I've also mentioned to my PCP that I'm having this procedure done and he didn't mention making sure that I stop the warfarin or at least making sure that the urologist was aware of it.

Am I being paraniod that this is an issue or is my cynicism valid when I believe that the doctors aren't as attentive to detail as they should be?

Thanks

Jerry

 

[geebee]

The only problem would be if the doctor is planning on removing any tissue for biopsy. Other than that, there should be no danger of bleeding. I would contact the doctor and find out whether he expects to be doing any cutting. If he is merely doing this to find out if something needs to be done in the future, then you should be fine to stay on the coumadin.

 

[Blanche]

Computec:
It would be my "guess" that you do not need to change your anticoagulation for a cyctocopy. If the doctor told you to discontinue anticoagulation without bridging therapy such as lovenox or heparin, that would be a concern. To the best of my knowledge, a cystocopy uses a scope for diagnostic purposes, but there is no cutting involved. THere are others here who are much more knowledgeable. I'm sure they will add their comments.

It is my understanding that people receiving anticoagulation therapy should be premedicated before the cystocopy. Was that explained to you?

Blanche

 

[Computec]

Thanks for the rapid replies, Blanche and Gina.

The doctor didn't mention the premedicating with antibiotics.

I've already had the CT scan and the kidneys were clear. I was making the assumption that if he spotted anything unusual during the cystoscopy that he'd do the cutting rather than repeat the procedure.

 

[Blanche]

Please check out Table 3 in this very long article, which is approved by the American Heart Assoication. It gives guidelines on premedicating and procedures. Cystoscopy is listed.
http://www.aafp.org/afp/980201ap/taubert.html
Blanche

 

[Ross]

Thanks for the rapid replies, Blanche and Gina.

The doctor didn't mention the premedicating with antibiotics.

I've already had the CT scan and the kidneys were clear. I was making the assumption that if he spotted anything unusual during the cystoscopy that he'd do the cutting rather than repeat the procedure.

He didn't mention them because once the procedure is done, he will give you some as a stop gap against infection. I.V. and some to take home for later in the day. There may be some irritational bleeding for a day or two after wards, but nothing serious.

 

[Computec]

Thanks, Blanche.

That's a very informative article. I'll keep that bookmarked so I can check up on the doctors that I see. My cardiologist reckons that, because of the A-Fib and the mechanical valve, I shouldn't come off the anticoagulates for more than three days. He never really addressed the antibiotic issue with me. I'll see him in July for the six month echo.

Ross...

You're saying that being at a 3 INR and having cutting done in this area is ok? And having the antibiotics given post procedure doesn't make much difference. I'm pretty new to all of this.

Thanks

Jerry

 

[Natanni]

I can not offer you advice in the warfarin dept, as our facility is rather old-school in warfarin; However, the Mayo infection control dept has stated that Nathan does need to be pre-medicated prior to any invasive procedures, cyctos being one, or anything involving the bladder (ex foley insertion, etc) as well as prostate exams. I am not sure if this is soley because he is now post endocarditis and at a higher risk of reinfection than murmur/post AVR people, I only know this is Mayo's instructions for him. When Nathan was in the hospital with endocarditis, we were told "any deep venous procedure lasting longer than 45 minutes" warrent pre-medication with antibiotics. Good luck with your cysto!

 

[Computec]

Well, Nattani...

I think that endocarditis is one of those things for which the adage "An ounce of prevention is worth a pound of cure." was coined. I just hope that my physicians don't put me at risk.

 

[DrAllan]

I presume that your urologic work up is because you have been having hematuria (blood in the urine). The CT of the kidneys is to rule our either kidney tumor or stones. An IVP (intravenous pylogram will demonstrate tumors of the ureters and bladder. However, there are superficial bladder tumors that are not easily detected by visual examination and ?blind? biopsies are needed to find or rule out. Most diagnostic cystoscopies are done under local anesthesia in the office or out patient department. Rarely is a biopsy done at this time, and if done is cauterized to control bleeding at the time. It is not necessary to stop Coumadin for this procedure. It is necessary to receive IV antibiotics, most likely garamycin (Gentamycin®). This is because in urologic procedures the most likely bacteria to enter the blood stream is a gram-negative organism. These are not sensitive to the amoxicillin taken for oral procedure prophylaxis. You will need to complete the IV infusion 1 hour prior to the procedure. You will have to check with your doctors regarding this since it seems that it has not been mentioned to you.

 

[Computec]

Thank you for your reply, Dr. Allan. I'll definitely pursue this with the urologist tomorrow. I'll post what his response is.

 

[Ross]

Ross...

You're saying that being at a 3 INR and having cutting done in this area is ok? And having the antibiotics given post procedure doesn't make much difference. I'm pretty new to all of this.

Thanks

Jerry

Jerry my urologist may be behind the times a bit, but I had this done while in the hospital and rather then having the infusion before the scope, I had it immediately afterwards. I'm not sure that 1 hour and 10 minutes makes all that much difference when infused, but as Blanche and Dr.Allan pointed out, it certainly isn't the norm. Sorry for the confusion.

 

[Guest]

I am pretty certain that my Dad stopped his warfarin for a cystoscopy, developed a blood clot in his leg that moved to his lung and killed him. I think that you are very fortunate if your doctor is willing to do the procedure without putting you at this risk. Are you really likely to bleed more than a quart if you continue warfarin? Try throwing a quart of milk on the kitchen floor. If the doc thinks that you are likely to bleed more than that ...

 

[DrAllan]

The rational for pre-procedure prophylaxis of antibiotics is that there should be a maximum concentration of the antibiotic in the blood stream. Then, when bacteria invade the blood there is the maximum chance of killing the bacteria at that point in time. To infuse the antibiotic post procedure is to try and treat bacteria that have already established themselves adherent to your valve and they are much harder to kill. Throw into this equation the fact that antibiotics tend to be classified as either bactericidal (those that kill bacteria) or bacteriostatic (those that prevent further growth and hopefully allow the immune mechanism to do the killing. Mechanically the body’s defense mechanisms at both the lining of the heart and in the brain are relatively ineffective compared to muscle and skin. Thus one prefers ‘cidal’ antibiotics in these regions if available. In this case the 'hour ten minutes" delay is crucual and improper.

 

[Ross]

Well I got lucky then. I didn't question it since it's the first I've had done since I was a little kid, plus being in the hospital with no way to research these things, it's not something I questioned. After all, they are the pro's right?

Looks like I got yet more education. Just to bad I didn't know it before. Of course, I wouldn't have won in the shape I was in anyway, but still..........

 

[Computec]

I spoke to my cardiologist and he told me that I should be stopping the warfarin and that, yes, the antibiotic that is "cidal" is the norm if there is to be any kind of biopsy.

In answer to your query, Dr. Allan, there is microscopic blood in my urine and, according to the physicians I am seeing, this should be investigated. From what I've read it's not uncommon for someone taking anticoagulant therapy to have blood in their urine. Other sources I've read say that there is no consensus on this.

Medical science is a crap shoot at times. Where's Dr. House when you need him? (Did you know that Hugh Laurie played the Prince on Black Adder?)

I'll be contacting my urologist and PCP a little later. It's only 7:30 AM in Hawaii.

 

[catwoman]

Jerry:

I'll bet that nearly everyone who is on warfarin has hematuria at some time or another.

Two years ago, I had my first physical post-op and my PCP found hematuria. He said it's extremely common with warfarin patients, but he wanted to rule out any tumors. I had an X-ray, then he wanted me to have the scoping done. I declined.
Last year I had some blood in the urine. This year, none.

 

[Ross]

I spoke to my cardiologist and he told me that I should be stopping the warfarin and that, yes, the antibiotic that is "cidal" is the norm if there is to be any kind of biopsy.

In answer to your query, Dr. Allan, there is microscopic blood in my urine and, according to the physicians I am seeing, this should be investigated. From what I've read it's not uncommon for someone taking anticoagulant therapy to have blood in their urine. Other sources I've read say that there is no consensus on this.

Medical science is a crap shoot at times. Where's Dr. House when you need him? (Did you know that Hugh Laurie played the Prince on Black Adder?)

I'll be contacting my urologist and PCP a little later. It's only 7:30 AM in Hawaii.

I would highly question stopping for this procedure unless they are sure they are biopsying and then do they plan on bridging you until you can restart and get in range?

 

[Computec]

Marsha...

Well, someone has to pay for the fancy offices and all that equipment. I'm surprised that you refused to do your part.

I spoke to my urologist and he said there is no need to stop the warfarin and that he'll address the antibiotic when I get there. Didn't sound like he appreciated me second guessing him. Kinda made me think that this one really IS God and not an imposter like the others.

Jerry

 

[Computec]

Hey, Al...

I don't mind the quart of milk on the floor but I draw the line at RED milk. What a visual. You made my day.

Jerry