What could be causing a 50-year-old male's hematuria (blood in urine), which worsens in the morning and after intercourse, with no accompanying pain or other symptoms, over the past 2 weeks?

Painless Gross Hematuria in a Late-50s Male: Urgent Urologic Evaluation Required

This patient requires immediate complete urologic evaluation with cystoscopy and multiphasic CT urography regardless of any other factors, as gross hematuria in a male of this age carries a 30-40% risk of urologic malignancy. 1, 2

Critical Risk Assessment

This presentation contains multiple high-risk features that mandate urgent investigation:

• Gross hematuria – visible blood carries 30-40% malignancy risk compared to only 2.6-4% with microscopic hematuria 1
• Male sex and age >50 years – men ≥40 years are classified as intermediate-to-high risk, with those ≥60 years being definitively high-risk 1, 3
• Painless nature – absence of pain increases suspicion for malignancy over benign causes like infection or stones 4, 5
• Pattern of bleeding (worse in morning/after intercourse) – suggests prostatic or bladder source rather than glomerular disease 4

The timing pattern (morning and post-coital) is particularly concerning for prostatic urethral or bladder neck pathology, including transitional cell carcinoma. 4

Mandatory Immediate Workup

Laboratory Evaluation

• Urinalysis with microscopy to confirm true hematuria (≥3 RBCs/HPF) and assess for dysmorphic RBCs or casts that would suggest glomerular disease 1, 6
• Urine culture before any antibiotics to exclude infection as a contributing factor 4, 1
• Serum creatinine to assess renal function 1, 6
• Voided urine cytology given high-risk status for urothelial malignancy 4, 1

Imaging

Multiphasic CT urography is the gold standard imaging modality and should include unenhanced, nephrographic, and excretory phases to comprehensively evaluate kidneys, collecting systems, ureters, and bladder for renal cell carcinoma, transitional cell carcinoma, and urolithiasis. 1, 6

• Traditional intravenous urography remains acceptable but has limited sensitivity for small renal masses 1
• If CT is contraindicated (renal insufficiency, contrast allergy), MR urography or renal ultrasound with retrograde pyelography are alternatives, though less optimal 1

Cystoscopy

Flexible cystoscopy is mandatory to directly visualize the bladder mucosa, urethra, and ureteral orifices for transitional cell carcinoma, which is the most frequently diagnosed malignancy in hematuria cases. 4, 1, 2

• Flexible cystoscopy is preferred over rigid as it causes less pain with equivalent or superior diagnostic accuracy 1, 2
• This must be performed even if imaging is negative, as small bladder lesions may not be visible on CT 4, 1

Why This Cannot Wait

Gross hematuria requires urgent urologic referral even if self-limited – the fact that bleeding has occurred for 2 weeks without resolution makes this even more concerning. 1, 2

• Hematuria can precede bladder cancer diagnosis by many years, making early detection critical for mortality and morbidity outcomes 2
• Bladder cancer detected at non-muscle invasive stages has dramatically better prognosis than muscle-invasive disease 4
• Delay in evaluation of gross hematuria is associated with worse oncologic outcomes 2

Common Pitfalls to Avoid

Do not attribute this to benign prostatic hyperplasia without proving it – while BPH can cause hematuria, it does not exclude concurrent malignancy, and gross hematuria from BPH must be proven through appropriate evaluation. 1

Do not defer evaluation if the patient is on anticoagulation or antiplatelet therapy – these medications may unmask underlying pathology but do not cause hematuria themselves, and evaluation must proceed regardless. 1, 3

Do not assume the post-coital timing makes this benign – while trauma can cause hematuria, the 2-week duration and morning exacerbation pattern suggest an underlying structural lesion rather than simple trauma. 4, 2

Do not order only ultrasound – renal ultrasound alone is insufficient for comprehensive upper tract evaluation in this high-risk patient. 1

Differential Diagnosis by Likelihood

Most Concerning (Requiring Exclusion)

• Bladder transitional cell carcinoma – most common malignancy presenting with painless gross hematuria in this demographic 4, 1
• Prostate cancer with urethral involvement – can cause hematuria worse with prostatic manipulation (intercourse) 4
• Renal cell carcinoma – presents with painless hematuria in 40-60% of cases 1

Benign But Requiring Confirmation

• Benign prostatic hyperplasia – common in this age group but must be proven as sole cause 1, 5
• Prostatic urethral varices – can cause intermittent bleeding worse with Valsalva or sexual activity 4
• Urolithiasis – typically painful but can occasionally present with painless hematuria 5, 7

Less Likely Given Presentation

• Urinary tract infection – absence of dysuria, frequency, or urgency makes this less likely 4, 5
• Glomerular disease – absence of tea-colored urine, proteinuria symptoms, or systemic signs makes this unlikely 1, 2

Follow-Up Protocol If Initial Evaluation Negative

If the complete urologic evaluation (CT urography + cystoscopy + cytology) is negative:

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit 1, 2
• Immediate re-evaluation warranted if: gross hematuria recurs, significant increase in microscopic hematuria, new urologic symptoms develop, or development of hypertension/proteinuria 1, 2
• Consider repeat cystoscopy at 12 months in high-risk patients with negative initial workup but persistent microscopic hematuria 1

The key message: gross hematuria in a male over 50 is malignancy until proven otherwise, and proving otherwise requires complete urologic evaluation with both imaging and direct visualization. 1, 2