What is the recommended workup for hematuria in a man with a history of prostate cancer?

From the Guidelines

The recommended workup for hematuria in a man with a history of prostate cancer should include a complete urologic evaluation, starting with a thorough history and physical examination, followed by urinalysis with microscopy and urine culture to rule out infection, as suggested by the American College of Radiology 1. This approach is necessary because hematuria in a man with prostate cancer history could represent various conditions including cancer recurrence, radiation cystitis, urinary tract infection, or a new primary malignancy such as bladder cancer. Key components of the workup include:

• Laboratory tests: complete blood count, comprehensive metabolic panel, and coagulation studies
• Imaging studies: CT urogram to evaluate the upper urinary tract for stones, tumors, or other abnormalities
• Cystoscopy: mandatory to directly visualize the bladder and urethra for potential sources of bleeding
• PSA testing: to assess for prostate cancer recurrence The urgency of evaluation depends on the severity of hematuria, with gross hematuria requiring more immediate attention than microscopic findings, as it has a high association with malignancy of up to 30% to 40% 1. Additionally, the American College of Physicians suggests that providers should be aware of risk factors for cancer when considering the finding of hematuria, and that timely referral may be neglected, even in high-risk subgroups 1. It is also important to note that the use of anticoagulant therapy does not alter the urologic evaluation of microhematuria 1. Overall, a comprehensive approach is necessary to ensure that all potential causes of hematuria are considered and addressed, prioritizing the patient's morbidity, mortality, and quality of life.

From the Research

Workup of Hematuria in a Man with a History of Prostate Cancer

The workup for hematuria in a man with a history of prostate cancer involves a thorough evaluation to determine the underlying cause of the hematuria.

• The etiology of gross hematuria in patients with prostate cancer varies according to primary treatment, with bladder cancer or infection being common causes after radical prostatectomy, and prostate cancer itself being a common cause when the primary treatment is not surgical 2.
• A study found that 60% of patients with prostate cancer who developed gross hematuria had the condition caused by the prostate cancer itself, highlighting the need for a comprehensive workup to rule out recurrence or progression of the cancer 2.
• The workup for hematuria should include a thorough history and physical examination to determine potential causes and assess risk factors for malignancy, as well as laboratory tests and imaging studies to evaluate the urinary tract 3.
• Prostate-specific antigen (PSA) testing may be useful in the workup of hematuria in men with a history of prostate cancer, as it can help identify patients with recurrent or progressive disease 4.
• In some cases, hematuria may be a presenting symptom of advanced prostate cancer, and a high PSA level can be indicative of this condition 5, 4.
• The evaluation of hematuria in a man with a history of prostate cancer should also consider other potential causes, such as bladder cancer, urinary tract infection, or benign prostatic hyperplasia, and should include a referral to a urologist for further evaluation and management 2, 3.