What is the next best step in managing a 58-year-old man with LUTS, hematuria, and a 40g prostate?

Management of LUTS with Hematuria in a 58-Year-Old Man

Cystoscopy is the next best step for this 58-year-old man with LUTS and microscopic hematuria. 1

Clinical Assessment

This patient presents with:

• 58-year-old man with bothersome lower urinary tract symptoms (LUTS)
• International Prostate Symptom Score (IPSS) of 18 (moderate-severe symptoms)
• Sexually active and wants to preserve ejaculation
• 40g smooth prostate on examination
• Post-void residual (PVR) of 20 mL (normal)
• PSA of 1.4 (normal)
• Microscopic hematuria (4 RBCs per high-power field)

Rationale for Cystoscopy

The presence of microscopic hematuria in this patient is the critical finding that necessitates cystoscopic evaluation before proceeding with any LUTS treatment. According to guidelines:

• Hematuria (microscopic or macroscopic) is a specific indication for endoscopic evaluation of the lower urinary tract 1
• Upper urinary tract imaging and endoscopy are indicated in patients presenting with hematuria 1
• When LUTS is associated with hematuria, the patient should be referred to a specialist (urologist) for appropriate evaluation before advising treatment 1

Management Algorithm

1. First priority: Evaluate hematuria

   • Cystoscopy is indicated due to microscopic hematuria
   • This is necessary to rule out bladder cancer or other urologic pathology

2. After excluding pathology:

   • If cystoscopy is negative, proceed with LUTS management
   • For a 40g prostate with moderate-severe symptoms (IPSS 18), medical therapy would be appropriate

3. Medical therapy options after ruling out pathology:

   • Alpha-blocker (tamsulosin) would be appropriate for this prostate size
   • Finasteride would be considered for larger prostates (typically >40g) 2

4. Minimally invasive procedures:

   • Prostatic urethral lift (PUL) or water vapor thermal therapy could be considered after ruling out pathology
   • These options preserve ejaculatory function, which is important to this patient

Why Not Other Options First?

• Tamsulosin (Option A): While appropriate for LUTS with this prostate size, the presence of hematuria requires evaluation first
• Finasteride (Option B): More appropriate for larger prostates (>40g); additionally, can cause sexual side effects including ejaculatory dysfunction 2
• Prostatic Urethral Lift/UroLift (Option D): Preserves ejaculation but requires ruling out pathology first
• Water Vapor Thermal Therapy (Option E): Preserves ejaculation but requires ruling out pathology first

Important Considerations

• Microscopic hematuria (>3 RBCs per high-power field) requires evaluation regardless of LUTS severity
• Delaying evaluation of hematuria could miss significant urologic pathology
• The patient's desire to preserve ejaculatory function is important but secondary to ruling out serious pathology
• After excluding pathology, treatment can be tailored to address both LUTS and sexual function preservation

The guidelines are clear that when LUTS is accompanied by hematuria, endoscopic evaluation is indicated before proceeding with treatment for LUTS 1. This approach prioritizes the detection of potentially serious conditions while still allowing for appropriate management of the patient's bothersome urinary symptoms.