What is the appropriate workup for a 74-year-old male with a history of Benign Prostatic Hyperplasia (BPH) and prostate cancer presenting with new onset hematuria?

Workup for a 74-Year-Old Male with BPH and Prostate Cancer Presenting with New Onset Hematuria

A comprehensive hematuria workup is mandatory for this patient, including cystoscopy, upper tract imaging, and urine cytology, as hematuria in a 74-year-old male with history of BPH and prostate cancer represents a high-risk scenario for urological malignancy.

Initial Assessment

The presentation of new onset hematuria in this patient requires urgent evaluation due to several high-risk factors:

• Advanced age (74 years)
• Male gender
• History of prostate cancer
• History of BPH

Laboratory Testing

1. Urinalysis and urine culture

   • To confirm hematuria and rule out infection 1
   • Assess for pyuria, bacteriuria, and other abnormalities

2. Urine cytology

   • Essential in this high-risk patient with history of malignancy
   • Helps detect urothelial carcinoma 1

3. PSA testing

   • Important to assess for prostate cancer progression
   • Useful in monitoring disease status in a patient with known prostate cancer 1

4. Complete blood count

   • To assess degree of blood loss and baseline hemoglobin

5. Renal function tests

   • Serum creatinine to assess kidney function 1

Imaging Studies

1. CT Urography

   • Preferred imaging modality for upper tract evaluation 1
   • Provides comprehensive assessment of kidneys, ureters, and bladder
   • Should be performed before any invasive procedures if solid/sessile tumor is suspected 1

2. If CT is contraindicated:

   • MRI urogram
   • Renal ultrasound with retrograde pyelogram 1

Endoscopic Evaluation

1. Cystoscopy

   • Mandatory to directly visualize the bladder and urethra 1
   • Should be performed by a urologist
   • Allows for assessment of:
     • Bladder tumors
     • Prostatic urethra
     • Bleeding sources in the prostate

2. Transurethral resection of suspicious lesions

   • If abnormalities are identified during cystoscopy
   • Provides tissue for histopathological examination 1

Special Considerations for This Patient

BPH-Related Hematuria

• BPH can cause hematuria due to increased vascularity of the prostate 2, 3
• However, in a patient with history of prostate cancer, this should be considered a diagnosis of exclusion

Prostate Cancer-Related Hematuria

• Prostate cancer itself can cause hematuria, especially in advanced disease 4
• Patients with prostate cancer who develop hematuria have a worse prognosis (median survival of 13 months after hematuria onset) 4

Bladder Cancer Risk

• Patients with hematuria and prostate cancer have a higher risk of bladder cancer
• In patients who underwent radical prostatectomy, bladder cancer was found to be the cause of hematuria in 38.5% of cases 4

Management Algorithm

1. Immediate management:

   • Assess hemodynamic stability
   • Consider bladder irrigation if clots are present
   • Treat any identified UTI

2. Diagnostic workup:

   • Complete laboratory testing (urinalysis, cytology, PSA, CBC, renal function)
   • CT urography
   • Cystoscopy by urologist

3. If bleeding source identified:

   • Directed treatment based on etiology
   • For BPH-related bleeding: consider 5-alpha reductase inhibitors (finasteride/dutasteride) 3, 5
   • For tumor-related bleeding: appropriate oncological management

4. If initial workup negative:

   • Consider prostatic urethral biopsies
   • Enhanced cystoscopic techniques (blue light cystoscopy if available) 1
   • Random bladder biopsies if indicated

Pitfalls to Avoid

1. Do not attribute hematuria solely to BPH without complete evaluation

   • Even with known BPH, malignant causes must be excluded 3

2. Do not delay evaluation

   • Gross hematuria has up to 30-40% association with malignancy 1

3. Do not stop at finding one potential cause

   • Multiple pathologies can coexist, especially in this high-risk patient

4. Do not forget to evaluate the upper urinary tract

   • Complete evaluation includes both lower and upper urinary tract assessment 1

5. Do not assume prostate cancer is the cause without ruling out bladder cancer

   • Bladder cancer is a common cause of hematuria in patients with history of prostate cancer 4

This patient requires urgent and thorough evaluation by a urologist with expertise in oncology, given his high-risk profile and concerning presentation.