What is the next step for a patient with urinary urgency, frequency, and hematuria, an enlarged prostate, a normal Prostate-Specific Antigen (PSA) level, and a normal bladder ultrasound?

Management of Urinary Urgency, Frequency, and Hematuria with Normal PSA and Enlarged Prostate

For a patient with urinary urgency, frequency, and hematuria with an enlarged prostate but normal PSA (<1) and normal bladder ultrasound, a complete urological evaluation with urine cytology and cystoscopy is strongly recommended to rule out bladder pathology, particularly bladder cancer. 1

Initial Diagnostic Workup

• Urinalysis should be repeated to confirm hematuria and screen for urinary tract infection, as hematuria requires thorough evaluation regardless of PSA level 1, 2
• Urine culture should be obtained to rule out infection, as UTIs can cause similar symptoms and can elevate PSA levels 2
• Urine cytology is indicated due to the presence of hematuria with irritative voiding symptoms, especially to aid in the diagnosis of bladder carcinoma in situ and bladder cancer 1, 3
• Cystoscopy is necessary to directly visualize the bladder and urethra to rule out bladder cancer, carcinoma in situ, urethral strictures, and bladder stones 1, 4

Rationale for This Approach

• The combination of hematuria with irritative voiding symptoms (urgency and frequency) raises concern for bladder pathology, even with normal PSA 2, 3
• Studies have shown that patients with chronic prostatitis-like symptoms and irritative voiding symptoms may have underlying bladder carcinoma in situ that can be missed without proper evaluation 3
• Normal PSA (<1) does not rule out significant urological pathology, including bladder cancer and certain prostate cancers that may not produce PSA 5
• An enlarged prostate on ultrasound is consistent with BPH but does not explain the hematuria, which requires separate evaluation 1, 4

Management Algorithm

1. Rule out infection first:

   • Obtain urinalysis and urine culture 1, 2
   • If infection is present, treat with appropriate antibiotics based on culture results 2

2. If hematuria persists after treating infection or no infection is found:

   • Obtain urine cytology 1, 3
   • Perform cystoscopy to directly visualize the bladder and urethra 1, 4

3. If bladder and urethral pathology are ruled out:

   • Consider treatment for BPH symptoms with alpha-blockers such as tamsulosin 6, 7
   • Alpha-blockers can improve both obstructive and irritative symptoms associated with BPH 6, 7

Important Caveats

• Do not attribute hematuria solely to BPH without proper evaluation, as this may lead to missed diagnoses of bladder cancer 4, 3
• While the PSA is normal, certain prostate cancers (such as basal cell carcinoma or small cell carcinoma) may present with hematuria and normal PSA levels 5
• Urine cytology is particularly important in patients with irritative voiding symptoms and hematuria, as studies have found bladder carcinoma in situ in patients previously diagnosed with chronic prostatitis 3
• Be aware that prostatic cysts can also cause similar symptoms and may require specific treatment if identified 8

Treatment Considerations

• If evaluation confirms BPH as the cause of symptoms, tamsulosin 0.4 mg daily is an appropriate initial treatment 6
• Tamsulosin has been shown to improve both AUA symptom scores and peak urine flow rates in patients with BPH 6
• Monitor for potential side effects of tamsulosin including orthostatic hypotension, dizziness, and retrograde ejaculation 6
• If symptoms do not improve with medical therapy and more serious conditions are ruled out, consider urological referral for evaluation of other minimally invasive treatment options for BPH 7