What is the best course of action for a 92-year-old male with a history of Gleason-7 prostate cancer (Prostate Cancer) and low-grade superficial bladder transitional cell carcinoma (TCC), currently experiencing gross hematuria, with a Prostate-Specific Antigen (PSA) level of 1.09, and taking finasteride (Proscar) and tamsulosin (Flomax) for Benign Prostatic Hyperplasia (BPH)?

Management of Gross Hematuria in a 92-Year-Old Male with BPH and History of Bladder and Prostate Cancer

Initial Assessment and Immediate Management

Gross hematuria in this 92-year-old male with BPH and history of bladder and prostate cancer requires immediate urologic evaluation with cystoscopy, urine cytology, and CT urography to rule out recurrent malignancy. 1, 2

The current management with Foley catheter placement and irrigation is appropriate as an initial intervention for the following reasons:

• Provides immediate relief of potential clot retention
• Allows for monitoring of ongoing bleeding
• Facilitates bladder irrigation to prevent clot formation
• Enables assessment of the severity and source of bleeding

Diagnostic Evaluation

A complete hematuria workup is essential given the patient's high-risk profile:

• Cystoscopy: Already planned in 3 days, which is appropriate timing. This is critical given the patient's history of low-grade superficial bladder TCC diagnosed 3 years ago 1, 2
• Urine cytology: Correctly planned to be obtained at follow-up 1
• CT urography: Appropriate plan for CT A/P with and without contrast to complete the hematuria evaluation 2, 3

Risk Factors for Malignancy

This patient has multiple risk factors that increase concern for malignancy:

• Age >90 years
• Male gender
• History of bladder cancer (low-grade superficial TCC)
• History of prostate cancer (Gleason-7 PCa s/p EBR)
• Smoking history (former smoker)
• Gross hematuria (higher risk than microscopic)

Etiology Considerations

The differential diagnosis for this patient's gross hematuria includes:

1. Recurrent bladder cancer: High priority given his history of bladder TCC 1
2. BPH-related bleeding: Likely contributor given obstructing lateral lobes and trabeculated bladder on recent cystoscopy 1
3. Antiplatelet medication effect: Aspirin may have contributed to or exacerbated bleeding
4. Radiation cystitis: Possible late effect from prior radiation therapy for prostate cancer
5. Urinary tract infection: Less likely given normal UA in July 2025

Treatment Plan Assessment

The current management plan is appropriate and includes:

1. Foley catheter placement with irrigation: Correctly performed to manage acute bleeding
2. Antibiotic prophylaxis: Appropriate with Augmentin 500 mg BID for 3 days
3. Follow-up cystoscopy in 3 days: Appropriate timing for reassessment
4. Surveillance cystoscopy in 6 months: Aligns with NCCN guidelines for bladder cancer follow-up 1
5. CT A/P with and without contrast: Appropriate imaging for complete hematuria evaluation 2, 3
6. Urine cytology: Correctly planned for follow-up

BPH Management Considerations

The patient's BPH is currently managed with:

• Tamsulosin (Flomax) 0.4 mg daily
• Finasteride (Proscar) 5 mg daily

This combination therapy is appropriate for his BPH with obstructing lateral lobes 1, 4, 5. Finasteride may help reduce the risk of future hematuria episodes, as 5-alpha reductase inhibitors can decrease prostatic bleeding 1.

Recommendations for Follow-up

1. Continue with planned cystoscopy in 3 days to directly visualize the source of bleeding and rule out recurrent bladder cancer
2. Proceed with CT urography as planned to evaluate the upper urinary tract
3. Obtain urine cytology as planned to screen for malignant cells
4. Consider continuing to hold aspirin until bleeding has completely resolved and malignancy has been ruled out
5. Maintain combination therapy with tamsulosin and finasteride for BPH management
6. Consider urologic consultation for possible TURP if bleeding recurs or is found to be primarily BPH-related, given the obstructing lateral lobes and trabeculated bladder

Cautions and Pitfalls

• Do not delay cystoscopy: Prompt evaluation is critical given the high risk of malignancy with gross hematuria (>10%) 6
• Do not attribute hematuria solely to aspirin use: While aspirin may contribute to bleeding, underlying pathology must be ruled out 2
• Do not neglect upper tract evaluation: CT urography is essential to evaluate for upper tract urothelial carcinoma 2, 3
• Avoid prolonged catheterization: Remove the catheter once bleeding resolves to reduce infection risk
• Consider age and comorbidities: Any surgical intervention must balance benefits against risks in this 92-year-old patient

The current management plan appropriately addresses both the acute bleeding episode and the need for thorough evaluation of this high-risk patient.