From the Guidelines
For a 77-year-old male with BPH presenting with gross hematuria and dysuria after recent UTI treatment, I strongly recommend an immediate and thorough urological evaluation to rule out underlying malignancy or other serious conditions, as gross hematuria has a high association with malignancy of up to 30% to 40% 1. The evaluation should include urinalysis, urine culture, complete blood count, and renal function tests to assess for any signs of infection, bleeding, or renal impairment.
- A post-void residual measurement should be performed to assess for urinary retention, which is a common complication in patients with BPH.
- Imaging with a renal ultrasound or CT urogram is indicated to evaluate for upper tract pathology, such as kidney stones or tumors, as recommended by the American College of Radiology 1. While awaiting results, empiric antibiotic therapy should be initiated with fluoroquinolones like ciprofloxacin 500mg twice daily or trimethoprim-sulfamethoxazole DS twice daily for 7-14 days, adjusting based on culture results, as suggested by the high-value care advice from the American College of Physicians 1. The patient should increase fluid intake to 2-3 liters daily to help clear hematuria and prevent clot formation. If significant bleeding continues, hospital admission may be necessary for continuous bladder irrigation. This presentation requires careful evaluation as it could represent treatment failure of the previous UTI, antibiotic resistance, or complications related to BPH such as urinary retention. The combination of BPH and recent UTI increases risk for persistent infection, as enlarged prostate tissue can harbor bacteria and impair complete bladder emptying, highlighting the need for a thorough evaluation and prompt treatment 1.
From the Research
Evaluation of Gross Hematuria and Dysuria
The evaluation of a 77-year-old male with a history of Benign Prostatic Hyperplasia (BPH) presenting with gross hematuria and dysuria one day after completion of treatment for a Urinary Tract Infection (UTI) involves a thorough investigation to determine the underlying cause.
- The patient's symptoms of gross hematuria and dysuria warrant a thorough history and physical to determine potential causes and assess risk factors for malignancy 2.
- Given the patient's age and history of BPH, the risk of malignancy with gross hematuria is a concern, and prompt urologic referral is recommended 2.
- The patient's recent completion of treatment for a UTI may be a contributing factor to the development of hematuria and dysuria, but it is essential to rule out other potential causes, such as urologic disease or other underlying conditions 3, 4.
Diagnostic Approach
The diagnostic approach for this patient may involve:
- Urine cytologic studies and urine cultures to rule out infection or malignancy 3.
- Excretory urograms with physiologic voiding films to evaluate the upper urinary tract 3.
- Cystoscopy and cystourethroscopy to evaluate the lower urinary tract and rule out bladder or urethral pathology 3, 5.
- Laboratory tests to rule out intrinsic renal disease or other underlying conditions 2, 5.
Referral Patterns
Primary care physicians may have varying approaches to referring patients with hematuria to urology, with some studies suggesting a reluctance to refer patients with gross or significant microscopic hematuria 5.
- However, given the patient's age and symptoms, prompt referral to a urologist is recommended to determine the underlying cause of the hematuria and dysuria and to initiate appropriate treatment 2.