What is the workup for a 50yo man with elevated PSA, suspected hematuria, and significant smoking history?

Workup for Suspected Hematuria in a 50-Year-Old Man with Elevated PSA and Smoking History

A comprehensive hematuria evaluation is mandatory for this 50-year-old man with elevated PSA, family history of prostate cancer, and 10 pack-year smoking history, as these risk factors significantly increase his risk for urologic malignancy. 1

Risk Assessment

This patient has multiple risk factors that require thorough evaluation:

• 50-year-old male (intermediate risk age category)
• Elevated PSA (concerning for prostate pathology)
• Family history of prostate cancer
• 10 pack-year smoking history (risk factor for bladder cancer)
• Suspected hematuria (even if potentially from dehydration)

According to the 2025 AUA/SUFU Microhematuria Guidelines, this patient would be classified as at least intermediate risk based on:

• Male sex, age 50 (intermediate risk category)
• 10 pack-year smoking history (intermediate risk category)
• Family history of urologic malignancy (additional risk factor) 1

Initial Evaluation

1. Confirm hematuria with urinalysis

   • Microscopic examination of urinary sediment to confirm RBC count
   • Definition of microhematuria: ≥3 RBCs/HPF on properly collected specimen 1

2. Basic laboratory studies

   • Complete blood count
   • Serum creatinine
   • Urinalysis with microscopy
   • Urine culture to rule out infection 1

3. PSA interpretation

   • Note that urinary tract infections can falsely elevate PSA
   • If infection is suspected, treat first and repeat PSA measurement after 4-6 weeks 2

Imaging Evaluation

Based on the patient's risk factors, the following imaging is recommended:

1. Upper tract imaging - CT urography is preferred 1

   • Provides comprehensive evaluation of kidneys, ureters, and bladder
   • Includes unenhanced images followed by nephrographic and excretory phases
   • Superior to ultrasound for detecting small renal masses and urothelial lesions 1

2. Prostate imaging

   • Consider multiparametric MRI of the prostate given the elevated PSA and family history 1
   • Helps identify suspicious lesions prior to potential biopsy

Cystoscopic Evaluation

Cystoscopy is indicated in this patient due to:

• Male sex and age >40 years
• Smoking history
• Suspected hematuria
• Elevated PSA 1

This procedure allows direct visualization of the bladder and urethra to identify any lesions, inflammation, or other abnormalities.

Prostate Evaluation

Given the elevated PSA and family history:

1. Detailed PSA evaluation

   • Consider PSA derivatives (free/total PSA ratio, PSA density)
   • Review PSA history/velocity if available 1

2. Digital rectal examination

   • Essential component of prostate cancer screening
   • Should be performed in conjunction with PSA testing 1

3. Prostate biopsy consideration

   • If PSA >10 ng/mL, biopsy is strongly recommended
   • For lower PSA values, consider risk factors, PSA velocity, and MRI findings
   • Extended 12-core biopsy scheme recommended if biopsy is performed 1

Special Considerations

• Transient hematuria: Even though the hematuria appears to be resolving, a complete evaluation is still warranted given the patient's risk factors 1

• Smoking history: Although 10 pack-years is at the lower threshold for increased risk, any smoking history increases risk for bladder cancer 1

• Prostate cancer family history: Increases risk for prostate cancer and warrants earlier and more frequent screening 1

Follow-up Recommendations

• If initial evaluation is negative but hematuria persists, consider repeat evaluation in 3-6 months
• If hematuria resolves and all tests are negative, continue age-appropriate prostate cancer screening given family history
• Smoking cessation counseling should be provided 1

This algorithmic approach ensures thorough evaluation of all potential causes of hematuria in this high-risk patient, with particular attention to ruling out urologic malignancies.