What is the best course of action for a 66-year-old male with an elevated Prostate-Specific Antigen (PSA) level, a lesion on the prostate, and flank pain, who is currently taking levofloxacin (levofloxacin) and has a history of cystoscopy, with a urinalysis showing hematuria (blood in the urine)?

Management of a 66-Year-Old Male with Elevated PSA, Prostate Lesion, Flank Pain, and Hematuria

This patient requires immediate urological referral for evaluation of possible upper urinary tract pathology and prostate cancer. 1

Initial Assessment

• The combination of elevated PSA, prostate lesion, flank pain, and hematuria represents a concerning clinical picture requiring prompt evaluation 1
• Current levofloxacin treatment may be addressing a urinary tract infection, but the underlying pathology needs further investigation 2
• Flank pain with hematuria raises concern for upper urinary tract pathology that requires imaging 1

Diagnostic Workup

Immediate Steps:

• Complete urinalysis and urine culture to confirm infection and assess antibiotic sensitivity 1
• Renal function tests to evaluate for possible renal impairment 1
• Upper urinary tract imaging (ultrasound or CT) is indicated due to:
  • Presence of hematuria (microscopic or macroscopic) 1
  • Flank pain suggesting possible upper tract involvement 1
  • History of urolithiasis (if present in patient history) 1

Prostate Evaluation:

• Transrectal ultrasound (TRUS) of the prostate to:
  • Assess prostate size and shape 1
  • Guide biopsy of the suspicious lesion 1
• Prostate biopsy is indicated due to:
  • Elevated PSA 1
  • Presence of a lesion on prostate 1
  • Need to rule out prostate cancer as a cause of symptoms 1

Treatment Approach

For Urinary Tract Infection:

• Evaluate effectiveness of current levofloxacin therapy 2, 3
• If symptoms persist or worsen, consider changing antibiotics based on culture results 4
• Complete the full course of appropriate antibiotics 2

For Prostate Pathology:

• If prostate cancer is diagnosed, staging and treatment will depend on:
  • Gleason score 1
  • Clinical stage 1
  • PSA level 1
  • Patient's overall health status 1

For Upper Tract Pathology:

• If imaging reveals urolithiasis, hydronephrosis, or other upper tract abnormalities, appropriate urological intervention will be required 1
• Persistent hematuria warrants urethrocystoscopy to evaluate for bladder or urethral pathology 1

Follow-up Plan

• Close monitoring of symptoms, particularly:
  • Resolution of flank pain 1
  • Clearance of hematuria 1
  • Normalization of urinalysis 1
• Repeat PSA testing after resolution of infection (as infection can falsely elevate PSA) 1
• Urological follow-up based on findings from initial evaluation 1

Important Considerations

• The combination of elevated PSA and a prostate lesion raises significant concern for prostate cancer, which requires definitive diagnosis 1
• Flank pain with hematuria could indicate pyelonephritis, urolithiasis, or other upper tract pathology requiring prompt evaluation 1
• Previous cystoscopy history suggests prior urological issues that may be relevant to current presentation 1
• Fluoroquinolones like levofloxacin can have adverse effects including nephrotoxicity in rare cases, which should be monitored 5