Is hematuria normal in a patient with prostate (pros ca) cancer?

Management of Hematuria in Patients with Prostate Cancer

Hematuria in patients with prostate cancer is not normal and requires prompt evaluation and management to rule out potentially serious underlying causes.

Etiology of Hematuria in Prostate Cancer Patients

The cause of hematuria varies based on the primary treatment the patient has received:

• After radical prostatectomy:

  • Bladder cancer (38.5%)
  • Urinary tract infection (23%)
  • Other causes unrelated to prostate cancer 1

• In non-surgically treated patients:

  • The prostate cancer itself (60% of cases)
  • Advanced disease with poor prognosis 1

Evaluation Algorithm

1. Determine severity of hematuria:

   • Gross (macroscopic) vs. microscopic hematuria
   • RTOG (Radiation Therapy Oncology Group) grade - higher grades have poorer resolution rates 2

2. Initial diagnostic workup:

   • Confirm hematuria with microscopic urinalysis (≥3 RBCs/HPF) 3
   • Renal and bladder ultrasound as first-line imaging 4
   • CT urography if available (sensitivity 92%, specificity 93%) 4
   • Cystoscopy to exclude bladder tumors or stones 5

3. Risk stratification:

   • Higher risk factors: age >60 years, male gender, smoking history, exposure to industrial chemicals, family history of renal cancer, history of pelvic radiation 4

Management Approach

Immediate Management

1. For all patients with gross hematuria:

   • Urethral catheterization 5
   • Bladder irrigation if needed 5
   • Blood transfusion for significant blood loss 5

2. For refractory hematuria:

   • Conservative management is successful in ~92% of cases 5
   • For persistent bleeding:
     • Selective Arterial Prostatic Embolization (SAPE) can be effective for refractory hematuria 6
     • Transurethral surgery may be required (effective in controlling hematuria) 1

Follow-up and Monitoring

• For patients with identified and treated causes:

  • Repeat urinalysis to confirm resolution 4
  • Monitor for recurrence

• For patients with negative evaluations:

  • Low-risk patients: annual urinalysis
  • Intermediate/high-risk patients: urine cytology and repeat urinalysis at 6,12,24, and 36 months 4

Important Considerations and Pitfalls

• Do not assume hematuria is normal in prostate cancer patients - always evaluate thoroughly
• Do not delay evaluation - delays in evaluation of gross hematuria can increase cancer-specific mortality by 34% 4
• Do not dismiss a single episode - a single episode of hematuria is equally concerning as recurrent episodes 4
• Do not obtain urinary cytology or urine-based molecular markers in the initial evaluation of hematuria 3
• Do not stop anticoagulant therapy without evaluation - pursue evaluation of hematuria even if the patient is on antiplatelet or anticoagulant therapy 3

Prognosis

• Patients with non-surgically treated prostate cancer who develop hematuria have a poorer prognosis (median survival of 13 months after hematuria onset) compared to post-radical prostatectomy patients (50 months) 1
• The severity (RTOG grade) of hematuria affects resolution rates in patients treated with hyperbaric oxygen therapy for radiation-induced hematuria 2

In rare cases, prostate cancer can present with hemolytic uremic syndrome, characterized by endothelial dysfunction, thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure 7.