How to manage a patient with a history of Benign Prostatic Hyperplasia (BPH) presenting with new urethral bleeding?

Management of Urethral Bleeding in a Patient with BPH

Gross hematuria in a BPH patient must first be proven to be of prostatic origin through appropriate evaluation, and a 5-alpha reductase inhibitor (finasteride or dutasteride) should be initiated to decrease the probability of prostate bleeding while ruling out other causes. 1

Immediate Diagnostic Evaluation

Before initiating treatment, the following must be completed:

• Perform urethrocystoscopy to confirm prostatic etiology and exclude bladder cancer, urethral stricture, or bladder stones as the source of bleeding 1
• Obtain urinalysis and urine culture to rule out urinary tract infection 1
• Check serum creatinine to assess for renal insufficiency secondary to BPH 1
• Measure post-void residual urine volume to evaluate for urinary retention 1
• Medical therapy is contraindicated in patients who have not been adequately evaluated or in patients with microscopic hematuria alone 1

Medical Management Algorithm

Once prostatic bleeding is confirmed:

• Start a 5-alpha reductase inhibitor (finasteride 5 mg daily or dutasteride 0.5 mg daily) as these medications decrease the probability of prostate bleeding by reducing prostate vascularity and volume 1, 2
• Finasteride reduces prostate volume by 17.9% over 4 years and decreases the risk of acute urinary retention by 57% and surgery risk by 55% 2
• Counsel patients that 5-ARIs have a slow onset of action - a therapeutic trial of at least 6 months is generally necessary to assess beneficial response 1, 2
• After 1 year of 5-ARI therapy, measured serum PSA values should be doubled to accurately gauge disease progression when screening for prostate cancer 1

Indications for Surgical Intervention

Surgery is recommended if the patient has: 1

• Recurrent gross hematuria refractory to medical therapy with 5-ARIs 1
• Renal insufficiency clearly due to BPH 1
• Recurrent urinary tract infections secondary to BPH 1
• Bladder stones clearly due to BPH 1
• Refractory urinary retention (failing at least one attempt at catheter removal) 1

Transurethral resection of the prostate (TURP) remains the gold standard surgical treatment for BPH with complications including recurrent hematuria refractory to medical management 3, 4

Critical Pitfalls to Avoid

• Never initiate medical therapy without first ruling out bladder cancer, urethral pathology, and other non-prostatic causes of hematuria through cystoscopy 1
• Do not assume microscopic hematuria alone warrants treatment - this is a contraindication to medical therapy without proper evaluation 1
• Avoid delaying surgical intervention if hematuria is recurrent and refractory to 5-ARI therapy, as this represents a serious complication of BPH 1
• 5-ARIs may also be considered preoperatively to reduce intraoperative bleeding and peri- or postoperative need for blood transfusion if surgery is planned 1

Special Considerations for Anticoagulated Patients

• In patients with thrombocytopenia or coagulopathy who develop severe refractory hematuria despite conservative measures, prostatic artery embolization may be considered as a salvage option 5
• However, this is not standard first-line therapy and should only be considered after failure of medical management and when surgical risk is prohibitive 5