Intravesicular Onabotulinumtoxin A Hemorrhage on Rivaroxaban

Overactive bladder (OAB) is urgency, with or without urgency incontinence. For OAB, an injection of onabotulinumtoxin A (BOTOX®) can be a low-risk outpatient procedure. We present a patient on a novel anticoagulant that experienced excessive bleeding after this procedure. This 80-year-old G2P2002 Caucasian female had a history of urge urinary incontinence. She presented for intravesicular onabotulinumtoxin A injection (150 units) after recent initiation of rivaroxaban (Xarelto®) for her atrial fibrillation. Several hours after an uncomplicated procedure, she presented with anuria and pain after gross hematuria earlier in the day. Her pain was immediately alleviated with bladder irrigation. She was discharged home and remained asymptomatic. With the popularity of the novel anticoagulants, new guidance on management of these medications during procedures is limited. When managing a patient on a novel anticoagulant before any procedure, even a low risk procedure, several factors should be considered to determine if the medication should be held, bridged, or continued. In sum, each patient on anticoagulation undergoing any procedure should be assessed individually for thrombotic risk, bleeding risk, and the procedural risk to best avoid postprocedural hemorrhage.