What is the initial workup and treatment for a patient presenting with Benign Prostatic Hyperplasia (BPH) and microhematuria?

From the Guidelines

The initial workup for a patient with BPH and microhematuria should include a thorough history and physical examination, urinalysis with culture, serum creatinine, PSA testing, and post-void residual measurement, as well as further evaluation for microhematuria using the AUA/SUFU Microhematuria Risk Stratification System 2025. When evaluating a patient with BPH and microhematuria, it is essential to consider the risk of malignancy, and the AUA/SUFU Microhematuria Risk Stratification System 2025 provides a framework for risk stratification based on factors such as age, smoking history, and degree of hematuria 1.

Initial Evaluation

The initial evaluation should include:

• A thorough history and physical examination, including a detailed smoking history and assessment of risk factors for genitourinary malignancy 1
• Urinalysis with culture to assess for infection or other causes of microhematuria
• Serum creatinine to assess renal function
• PSA testing to assess for prostate cancer
• Post-void residual measurement to assess for urinary retention

Microhematuria Evaluation

For patients with microhematuria, further evaluation is necessary to rule out malignancy, and the AUA/SUFU Microhematuria Risk Stratification System 2025 should be used to determine the risk of malignancy 1.

• Low-risk patients may not require further evaluation, while intermediate- and high-risk patients should undergo upper tract imaging (CT urography or renal ultrasound) and urine cytology to rule out malignancy

BPH Treatment

For BPH treatment, alpha-blockers like tamsulosin (0.4 mg daily) are first-line medications, providing rapid symptom relief by relaxing prostatic smooth muscle.

• 5-alpha reductase inhibitors such as finasteride (5 mg daily) or dutasteride (0.5 mg daily) can be added for larger prostates (>40g) to reduce prostate size over 3-6 months
• Combination therapy is more effective for moderate-to-severe symptoms
• Anticholinergics may help with overactive bladder symptoms if post-void residual is low
• Patients should be counseled on lifestyle modifications including fluid restriction before bedtime, limiting caffeine and alcohol, and timed voiding
• If medical therapy fails or complications like recurrent UTIs, bladder stones, or refractory retention occur, surgical options like TURP should be considered, as recommended by the AUA guideline on the management of lower urinary tract symptoms attributed to BPH 1. Regular follow-up is essential to monitor symptom improvement and assess for complications.

From the FDA Drug Label

The provided drug labels do not directly address the initial workup and treatment for a patient presenting with Benign Prostatic Hyperplasia (BPH) and microhematuria.

The FDA drug label does not answer the question.

From the Research

Initial Workup for BPH and Microhematuria

The initial workup for a patient presenting with Benign Prostatic Hyperplasia (BPH) and microhematuria involves several steps:

• A thorough history and physical examination to identify potential causes of hematuria and assess the severity of BPH symptoms 2
• Measurement of inflammatory parameters and renal function tests to evaluate kidney function and detect any potential kidney damage 2
• Ultrasonography of the kidneys and bladder to visualize the urinary tract and detect any abnormalities 2
• Urine microscopy to confirm the presence of microhematuria and rule out other causes of hematuria 2

Diagnostic Evaluation of Microhematuria

The diagnostic evaluation of microhematuria is crucial to identify potential underlying conditions:

• Patients with non-glomerular asymptomatic microhematuria (aMH) who have risk factors such as smoking, advanced age, and male sex should undergo augmented, risk-adapted diagnostic evaluation with urethrocystoscopy, urine cytology, and, when indicated, CT urography 2
• Patients with isolated glomerular hematuria are at elevated risk for renal disease and should undergo follow-up checks at six-month intervals 2
• Existing guidelines vary in their definition of aMH, the age threshold for recommending evaluation, and the optimal imaging method 3

Treatment of BPH

The treatment of BPH involves medical management with various medications:

• 5-alpha reductase inhibitors, such as finasteride, can reduce prostate volume and improve symptoms 4
• Alpha-1 antagonists, such as tamsulosin, can relax the muscles in the prostate and bladder neck, improving urine flow 5
• Combination therapy with 5-alpha reductase inhibitors and alpha-1 antagonists can be considered for patients with moderate to severe symptoms 5
• Other treatment options, such as anticholinergics, PDE5 inhibitors, and beta-3 agonists, may also be considered based on patient response and symptoms 5