What is the next best step for a 57-year-old male with a 2-month history of hematuria and suprapubic discomfort, who has not improved with multiple courses of Cipro (ciprofloxacin)?

Urgent Urologic Referral for Cystoscopy and CT Urography

This 57-year-old male with 2 months of persistent hematuria and suprapubic discomfort despite multiple courses of ciprofloxacin requires immediate complete urologic evaluation with cystoscopy and upper tract imaging (CT urography) to exclude malignancy—this presentation carries a 30-40% risk of urologic cancer and should never be attributed to infection when antibiotics have failed. 1

Why Antibiotics Have Failed and What This Means

• Ciprofloxacin does not cause hematuria—the medication may only unmask underlying urinary tract pathology that requires investigation, and persistent symptoms after multiple courses strongly suggest a non-infectious etiology 1
• The 2-month duration of symptoms despite appropriate antibiotic therapy effectively rules out simple urinary tract infection as the sole cause 2
• Gross or persistent microscopic hematuria with irritative symptoms (suprapubic discomfort) in a 57-year-old male is a high-risk presentation for bladder cancer, with males ≥40 years automatically classified as intermediate-to-high risk requiring full evaluation 1, 3

Immediate Next Steps

1. Confirm True Hematuria (If Not Already Done)

• Obtain microscopic urinalysis showing ≥3 red blood cells per high-power field to confirm true hematuria, as dipstick alone has only 65-99% specificity 4
• Document the degree of hematuria (number of RBCs/HPF) and whether gross or microscopic 1

2. Urgent Urologic Referral for Complete Evaluation

Do not delay—this patient needs both upper and lower tract evaluation regardless of any "benign" findings: 1, 3

Lower Tract Evaluation (Mandatory)

• Flexible cystoscopy to visualize bladder mucosa, urethra, and ureteral orifices—this is non-negotiable for all males over 40 with hematuria, even if upper tract imaging reveals a benign source 3
• Flexible cystoscopy is preferred over rigid as it causes less pain with equivalent or superior diagnostic accuracy 1, 3
• Voided urine cytology should be obtained given his high-risk status (age >40, male, persistent symptoms) to detect high-grade urothelial carcinomas 3

Upper Tract Evaluation (Mandatory)

• Multiphasic CT urography is the preferred imaging modality for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis 1, 3
• This includes unenhanced, nephrographic phase, and excretory phase images to comprehensively evaluate kidneys, collecting systems, ureters, and bladder 1

3. Additional Laboratory Testing

• Serum creatinine to assess renal function and identify potential renal parenchymal disease 3
• Complete urinalysis with microscopy to assess for red cell casts or dysmorphic RBCs (>80%) suggesting glomerular disease, which would prompt nephrology referral 1

Critical Risk Factors to Document

This patient's presentation includes multiple high-risk features that mandate urgent evaluation: 1, 3

• Age 57 years (males ≥40 are intermediate-to-high risk) 1
• Suprapubic discomfort/irritative symptoms—these are high-risk features for urothelial malignancy, not just infection 1
• Persistent symptoms despite appropriate antibiotic therapy—strongly suggests non-infectious etiology 2

Additional risk factors to specifically query:

• Smoking history (especially >30 pack-years is high risk) 1, 3
• Occupational exposure to benzenes, aromatic amines, chemicals, or dyes 1, 3
• Any history of gross hematuria episodes 1, 3

Common Pitfalls to Avoid

• Do not prescribe additional courses of antibiotics—this delays cancer diagnosis and provides false reassurance 2, 1
• Do not defer cystoscopy based on finding a "benign" cause like BPH on imaging—bladder cancer must still be excluded in this age group 3
• Do not assume suprapubic discomfort is "just prostatic" without complete evaluation—the cancer risk is age-dependent, not symptom-dependent 3
• Do not obtain urine culture in this asymptomatic (from infection standpoint) patient—hematuria requires evaluation for urologic causes including malignancy, not antibiotic treatment 1

If Initial Workup is Negative

Even if the complete urologic evaluation is negative, this patient requires surveillance: 3

• Repeat urinalysis, urine cytology, and blood pressure at 6,12,24, and 36 months 3
• Immediate re-evaluation if recurrent gross hematuria, significant increase in microscopic hematuria, or new urologic symptoms occur 3
• The appearance of hematuria can precede cancer diagnosis by years, making long-term surveillance critical 3

When to Consider Nephrology Referral Instead

Consider nephrology consultation if the patient has features suggesting glomerular disease: 1

• Significant proteinuria (protein-to-creatinine ratio >0.2) 1
• Red cell casts (pathognomonic for glomerular bleeding) 1

• 80% dysmorphic RBCs on phase contrast microscopy 1

• Tea-colored or cola-colored urine 1
• Hypertension accompanying hematuria 1

However, even with glomerular features, urologic evaluation should still be completed in this high-risk patient to exclude concurrent malignancy. 1