Dabigatran Induced Hemorrhagic Cystitis in a Patient with Painful Bladder Syndrome

An 82-year-old female presented with longstanding history of both painful bladder syndrome and atrial fibrillation. She underwent hydrodistension remarkable for hematuria without temporary discontinuation of Dabigatran. Subsequently, patient was admitted to the hospital secondary to anemia and hemorrhagic cystitis. 1. Introduction Dabigatran (Pradaxa) is a direct thrombin inhibitor which is used as an anticoagulant [1]. The recommended monitoring parameters for Dabigatran are less stringent than those for warfarin [2, 3]. Patients undergoing minor surgical procedures at minimal risk of bleeding may remain on Dabigatran. Dabigatran has not been previously associated with hemorrhagic cystitis. 2. Case An 82-year-old female with painful bladder syndrome presented with worsening symptoms of pelvic pain, dysuria, frequency, and urgency. Her past medical history was significant for atrial fibrillation, cerebrovascular accident, arthritis, and hypothyroidism. Patient’s past history was significant for a prior hydrodistension resulting in resolution of her symptoms for a few months. She underwent a CT abdomen and pelvis with/without contrast which revealed a diffuse thickening of the urinary bladder wall and no focal renal lesion or hydronephrosis. After an in-office cystourethroscopy, which was significant for hypervascularity and decreased capacity, she underwent four bladder instillations, with a mixture of marcaine, heparin, and saline, without relief of her symptoms. After each instillation, patient complained of small volume gross hematuria. Hydrodistension of her bladder was scheduled. However, at the time of her scheduled hydrodistension, the bladder was noted to be filled with a large blood clot. Bladder washings and biopsy were obtained at this time and the hydrodistension was not completed. No focus of bleeding could be identified. Visualization was markedly diminished. Clinical followup was planned for 2 days later. The pathology from the washings and biopsy revealed bladder mucosa with chronic inflammation, negative for malignancy. The patient subsequently was admitted to the hospital secondary to acute anemia, with a hematocrit (Hct) of 19.1% and a hemoglobin (Hgb) of 6.7？g/dL. She underwent transfusion with 4 units of PRBC, 5 units of frozen plasma, and 1 unit of platelets. An intravenous pyelogram revealed an intact bladder. Continuous bladder irrigation was performed. Significant laboratory results included PTT-SSH of 26.3 (11.1–13.5) seconds, PT of 2.3 (9.7–12.9) seconds, and PTT of 123.0 (24–34) seconds. Dabigatran was discontinued and