What are the management and evaluation options for a patient experiencing hematuria and spontaneous erections after prostate resection?

Management of Hematuria and Spontaneous Erections Post-Prostate Resection

Both hematuria and spontaneous erections after prostate resection require thorough urologic evaluation to exclude malignancy or significant structural complications, while recognizing that both can represent expected postoperative phenomena that often resolve spontaneously.

Hematuria Evaluation and Management

Initial Assessment

• Hematuria occurring more than 2 years post-prostatectomy requires full urologic investigation regardless of prior negative workup, as 43% of patients will have demonstrable pathology and 10% may harbor urinary tract malignancy 1
• Confirm true hematuria with microscopic urinalysis showing ≥3 red blood cells per high-power field, as dipstick testing has false-positive rates up to 33% 2
• Document timing of hematuria onset relative to surgery, frequency of episodes, presence of clots, and any associated lower urinary tract symptoms 3

Risk Stratification

• Early hematuria (within first 2 years): More commonly benign and related to healing prostatic fossa, though still requires evaluation 1
• Late hematuria (>2 years post-surgery): Higher likelihood of new pathology including malignancy, urethral stricture, or bladder pathology 1
• Assess for anticoagulation/antiplatelet therapy, which increases bleeding risk but should not preclude full evaluation 4, 5
• Consider radiation history if patient received post-prostatectomy radiotherapy, as 8-year freedom from grade 2+ hematuria is only 55% in this population 5

Mandatory Diagnostic Workup

• Cystoscopy to visualize bladder and prostatic fossa for telangiectasias, residual prostatic tissue, bladder lesions, or urethral stricture 2, 1
• Upper tract imaging with CT urography (preferred) or renal ultrasound to exclude upper tract pathology 2
• Serum creatinine and urinalysis with assessment for proteinuria, infection, and dysmorphic red blood cells 4
• Do not obtain urine cytology in initial evaluation as it is not recommended 2

Management Based on Findings

If benign prostatic regrowth identified:

• Trial of 5-alpha reductase inhibitor (finasteride) controls hematuria in 51% of cases with minimal rebleeding at 18-month follow-up 6
• Reassurance alone appropriate if single isolated episode with normal cystoscopy 6, 7
• Repeat TURP indicated for persistent symptomatic bleeding from vascular regrowth 6

If radiation-related telangiectasias:

• Typically self-limited; 88% resolve by 24 months from first bleeding episode 7
• Fulguration of bleeding sites during cystoscopy for persistent cases 5
• Limit bladder V65 Gy <43% in future radiation patients to reduce risk 5

If active arterial bleeding identified:

• CT angiography to localize bleeding source 8
• Selective arterial embolization is treatment of choice, avoiding surgical revision 8

Follow-up Protocol

• For persistent hematuria after negative initial evaluation: repeat urinalysis at 6,12,24, and 36 months 4
• Nephrology referral if hematuria persists with hypertension, proteinuria, or glomerular bleeding pattern 4
• Do not attribute hematuria solely to anticoagulation or BPH without proper evaluation 4, 2

Spontaneous Erections Post-Prostatectomy

Understanding the Phenomenon

• Return of spontaneous erections after nerve-sparing prostatectomy represents recovery of erectile function, which can be delayed by 1-2 years in some men 3
• Erectile function recovery is gradual and variable, with maximal function potentially not achieved until 12-24 months postoperatively 3
• This is generally a positive prognostic sign indicating preserved neurovascular bundle function 3

Assessment Approach

• Document quality, frequency, and rigidity of erections 3
• Assess whether erections are adequate for penetration or causing distress 3
• Inquire about concurrent use of PDE5 inhibitors or other erectile aids, as many men use these during recovery 3
• Evaluate for priapism if erections are prolonged (>4 hours) or painful, though this is extremely rare post-prostatectomy

Management Strategy

• Reassure patient that spontaneous erections indicate successful nerve preservation and functional recovery 3
• If erections are inadequate for intercourse despite spontaneous activity, consider PDE5 inhibitor optimization 3
• Include partner in discussions about sexual function recovery and expectations 3
• Refer to sex therapy or couples counseling if psychological distress present 3

Common Pitfalls to Avoid

• Never delay hematuria evaluation assuming it is "normal" post-surgical bleeding, especially beyond 2 years 1
• Do not rely on dipstick alone; always confirm with microscopic examination 2
• Do not attribute hematuria to anticoagulation without full urologic workup 4, 2
• Do not dismiss spontaneous erections as problematic; they typically indicate positive recovery 3
• Avoid omitting cystoscopy even in younger patients with microscopic hematuria 4