What is the next step in the workup for a patient with gross hematuria, 1+ crystals in the urine, elevated Prostate-Specific Antigen (PSA) level, and a family history of prostate cancer?

Evaluation and Management of Gross Hematuria with Elevated PSA and Family History of Prostate Cancer

For a patient with gross hematuria, 1+ crystals in urine, elevated PSA, and family history of prostate cancer, the next step should be a transrectal ultrasound-guided prostate biopsy to rule out prostate cancer.

Risk Assessment and Rationale

Gross hematuria in this patient presents with several concerning features:

• Elevated PSA: A significant risk factor for prostate cancer, especially with family history
• Family history of prostate cancer: Increases baseline risk
• Gross hematuria: Requires urgent evaluation with >10% risk of malignancy 1
• Crystals in urine: May suggest urolithiasis but doesn't explain all findings

This combination of findings creates a high-risk profile that warrants immediate evaluation for prostate cancer as the most concerning potential diagnosis.

Diagnostic Algorithm

1. Prostate Biopsy:

   • Transrectal ultrasound-guided prostate biopsy is indicated when PSA is elevated above the locally accepted reference range 2
   • Standard approach includes 10-12 core samples 2
   • Should be performed with:
     • Rectal preparation by enema
     • Prophylactic antibiotics against Gram-negative bacteria 2

2. Concurrent Imaging:

   • CT urography has 92% sensitivity and 93% specificity for detecting urinary tract malignancies 3
   • Should be performed to evaluate the upper urinary tract given the presence of gross hematuria

3. Additional Testing:

   • Urine cytology to evaluate for bladder carcinoma in situ, especially with irritative symptoms 2
   • Complete blood count to assess for anemia from blood loss
   • Renal function tests to evaluate kidney function

Special Considerations

Prostate Biopsy Technique

• Local anesthesia is typically sufficient for most patients 2
• 10-12 core samples should be taken, with additional samples from any suspicious areas 2
• Patient should be informed about potential complications including bleeding, infection, and urinary retention

Crystals in Urine

While 1+ crystals may suggest urolithiasis, this finding alone doesn't explain the elevated PSA and family history. The crystals may be:

• Incidental finding
• Related to urinary stasis from possible prostatic enlargement
• Secondary to urinary tract inflammation

Timing

Delays in evaluation of gross hematuria can increase cancer-specific mortality by 34% 3, making prompt evaluation essential.

Post-Biopsy Management

Based on biopsy results:

• If positive for prostate cancer:

  • Staging workup including bone scan and pelvic MRI
  • Treatment options based on stage, grade, and patient factors

• If negative for prostate cancer:

  • Complete hematuria workup including cystoscopy to evaluate bladder
  • Consider repeat prostate biopsy if PSA continues to rise 2

Common Pitfalls to Avoid

1. Attributing hematuria solely to crystals/stones - While crystals may suggest urolithiasis, the elevated PSA and family history of prostate cancer require evaluation

2. Delaying prostate biopsy - The combination of gross hematuria and elevated PSA requires prompt evaluation

3. Incomplete evaluation - Even if prostate cancer is found, a complete hematuria workup may still be necessary as patients can have multiple pathologies

4. Inadequate biopsy sampling - Ensure adequate sampling with at least 10-12 cores to minimize false-negative results

By following this approach, you can efficiently diagnose the cause of this patient's gross hematuria while appropriately addressing the elevated PSA and family history of prostate cancer.