Should I order a routine (non‑urgent) CT abdomen and pelvis with and without contrast (CT urography) for a 63‑year‑old male with a single episode of gross hematuria and a history of benign prostatic hyperplasia (BPH) but no history of prostate cancer, bladder cancer, or kidney stones?

Order a routine (non-urgent) CT urography (CT abdomen and pelvis without and with IV contrast)

This 63-year-old male with gross hematuria requires a full urologic workup including CT urography, but this can be scheduled routinely rather than emergently unless he is hemodynamically unstable or has urinary retention from clot obstruction. 111

Why CT Urography is Indicated

Your patient has gross (frank) hematuria, which carries a 30-40% risk of malignancy 11. The ACR Appropriateness Criteria explicitly state that all patients with gross hematuria should have a full urologic workup 1. His risk factors compound this concern:

• Male gender (relative risk 2.04 for upper tract malignancy) 2
• Age >35 years (relative risk 2.95 when >50 years) 12
• History of urologic disease (BPH) 1

The ACR guidelines are unequivocal: CTU without and with IV contrast is usually appropriate for the initial imaging of gross hematuria 1. While his BPH could theoretically explain the bleeding, this does not obviate the need for comprehensive imaging to exclude malignancy.

Routine vs. STAT Timing

Order this as routine, not STAT, unless:

• He is hemodynamically unstable (hypotensive, tachycardic, requiring transfusion)
• He has acute urinary retention from clot obstruction
• He has ongoing massive hemorrhage requiring active resuscitation

A single episode of gross hematuria in a stable patient warrants thorough evaluation but not emergency imaging. The goal is cancer detection and anatomic assessment, which doesn't require immediate same-day scanning in a stable patient.

Correct Protocol Confirmation

Yes, you are correct to order CT abdomen and pelvis without and with contrast - this is CT urography (CTU). The protocol should include 11:

• Unenhanced (non-contrast) phase - essential for detecting stones and baseline assessment
• Nephrographic phase - for renal parenchymal masses
• Excretory/delayed phase (at least 5 minutes post-contrast) - critical for visualizing the collecting system, ureters, and bladder for urothelial tumors
• Thin-slice acquisition with multiplanar reconstructions

Common Pitfalls to Avoid

1. Don't assume BPH explains everything: While BPH is a common benign cause of hematuria 1, it doesn't exclude concurrent malignancy. The 30-40% cancer risk in gross hematuria supersedes the BPH diagnosis 11.

2. Don't order a standard "CT abdomen/pelvis with contrast" without specifying urography protocol: A routine CT with only one contrast phase will miss urothelial lesions. You need the three-phase protocol 11.

3. Don't skip imaging because he's seeing urology: The urologist will need the CTU results before cystoscopy to plan the complete evaluation 1.

4. Don't order ultrasound instead: Ultrasound has only 35% sensitivity for bladder pathology and poor ureteral visualization 1. It's inadequate for gross hematuria workup in this patient.

Coordination with Urology

The patient should undergo both CTU and cystoscopy as part of the complete gross hematuria evaluation 1. The CTU evaluates the upper tracts (kidneys, ureters) while cystoscopy directly visualizes the bladder and urethra. These are complementary, not alternatives. Coordinate with his urologist so the imaging is completed before the cystoscopy appointment.