Should a 60-year-old male with a history of Benign Prostatic Hyperplasia (BPH), Cerebrovascular Accident (CVA), Atrial Fibrillation (Afib) on Pradaxa (dabigatran) 110mg PO twice daily (BD) with persistent painless hematuria be referred to the hospital?

Management of Persistent Painless Hematuria in a 60+ Male on Anticoagulation

A 60-year-old male with persistent painless hematuria (2+ blood on dipstick) for over 2 months should be urgently referred to urology for evaluation, regardless of his anticoagulation status with Pradaxa. 1

Risk Assessment

This patient presents with several concerning features:

• Persistent hematuria (>2 months)
• Male gender over 60 years old (high-risk age group)
• History of BPH (can cause hematuria but also increases risk of bladder cancer)
• On anticoagulation therapy (Pradaxa 110mg twice daily)

Key Considerations

1. Anticoagulation is not an excuse to ignore hematuria

   • Per ACP High-Value Care Advice 6: "Clinicians should pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy." 1
   • Anticoagulation may contribute to hematuria but does not explain its persistence or rule out underlying pathology

2. Malignancy risk is significant

   • Painless hematuria has a stronger association with cancer than symptomatic hematuria 1
   • Men over 60 are at higher risk for urologic malignancies
   • Case reports demonstrate that early evaluation of hematuria in patients on anticoagulants can lead to early detection of malignancy 2

Diagnostic Algorithm

1. Confirm hematuria with microscopic analysis

   • Verify that dipstick positive result shows ≥3 RBCs per high-powered field 1
   • The patient's dipstick shows 2+ blood, which warrants microscopic confirmation

2. Evaluate for benign causes

   • UTI should be ruled out (leukocytes 3+ suggests possible infection)
   • However, even with potential infection, persistent hematuria requires evaluation

3. Referral decision

   • Given the persistence of hematuria for over 2 months, referral is indicated regardless of anticoagulation status
   • The American College of Physicians recommends: "Clinicians should consider urology referral for cystoscopy and imaging in adults with microscopically confirmed hematuria in the absence of some demonstrable benign cause." 1

Expected Urologic Evaluation

Upon referral, the patient should undergo:

1. Cystoscopy to directly visualize the bladder and urethra 1, 3

2. Upper tract imaging to evaluate kidneys and ureters 1, 3

   • Transabdominal ultrasonography as first-line imaging 3
   • Possibly CT urography depending on risk factors

3. Urine cytology may be considered, though not recommended for initial evaluation 1

Follow-up Recommendations

• If initial evaluation is negative, annual urinalysis should be conducted 1
• For persistent or recurrent hematuria after negative workup, repeat evaluation within 3-5 years 1
• More frequent monitoring may be needed given the patient's risk factors

Common Pitfalls to Avoid

1. Attributing hematuria solely to anticoagulation

   • This is a dangerous assumption that may delay diagnosis of serious conditions 2

2. Delaying referral due to BPH history

   • While BPH can cause hematuria, it should not prevent proper evaluation
   • The AUA notes that "malignant causes of AMH may be masked by the presence of these other entities" 1

3. Inadequate follow-up

   • Even if initial evaluation is negative, continued surveillance is necessary 1

4. Relying on symptoms alone

   • Painless hematuria is particularly concerning for malignancy 1

In conclusion, this patient requires urgent urologic referral for comprehensive evaluation of his persistent hematuria, regardless of his anticoagulation status or BPH history.