What is the next step for an elderly male patient, status post Transurethral Resection of the Prostate (TURP) 1 month ago, presenting with urinary urgency, nocturia 7-10 times, and recent hematuria that resolved 3 days ago?

Post-TURP Urinary Symptoms at 1 Month

This patient requires urinalysis with urine culture and post-void residual measurement, followed by a 3-day frequency-volume chart to differentiate between overactive bladder symptoms and nocturnal polyuria. 1, 2

Immediate Diagnostic Workup

Essential First Steps

• Obtain urinalysis and urine culture to exclude urinary tract infection, which is more common in older men post-TURP due to urinary stasis and instrumentation 2
• Measure post-void residual (PVR) urine volume via bladder ultrasound to assess for incomplete bladder emptying or urinary retention (PVR >100-200 mL is significant) 1, 2
• Request a 3-day frequency-volume chart (voiding diary) to document time and volume of each void, particularly overnight, to identify nocturnal polyuria (>33% of 24-hour output at night) versus reduced bladder capacity 1, 2, 3

Physical Examination Focus

• Perform digital rectal examination to assess for prostatic tenderness suggesting infection or incomplete resection 2
• Examine suprapubic area for bladder distention 2
• Assess lower extremities for edema, which may indicate fluid redistribution contributing to nocturia 4, 1

Clinical Context and Differential

Post-TURP Timeline Considerations

At 1 month post-TURP, this presentation is concerning because:

• Recent hematuria (resolved 3 days ago) warrants investigation even after resolution, as post-TURP bleeding can indicate incomplete healing, infection, or residual pathology 5, 6
• Severe nocturia (7-10 times) with urgency suggests either overactive bladder symptoms or nocturnal polyuria rather than expected post-operative recovery 4, 3
• The acute effects of TURP (irritative symptoms from edema) typically improve gradually and stabilize by 1 month, making persistent severe symptoms abnormal 4

Key Diagnostic Distinctions

The frequency-volume chart is critical to differentiate:

• Nocturnal polyuria: Normal or large volume voids at night (>33% of 24-hour output), often related to cardiovascular disease, sleep disorders, or fluid redistribution 4, 3
• Overactive bladder: Small frequent voids with urgency, responding to anticholinergic therapy 4, 3
• Incomplete bladder emptying: Elevated PVR suggesting obstruction from urethral stricture or bladder neck contracture 4, 1

Management Algorithm Based on Findings

If Infection is Present (Positive UA/UCx)

• Initiate empiric antibiotic therapy based on local resistance patterns 2
• All UTIs in men are considered complicated and require thorough evaluation 2
• Re-evaluate after antibiotic completion to assess symptom resolution 2

If PVR is Elevated (>100-200 mL)

• Consider urethral stricture or bladder neck contracture as post-TURP complications 4, 1
• Trial of alpha-blocker therapy (e.g., tamsulosin) may be appropriate 1
• Refer to urology if PVR remains elevated or symptoms persist, as this may require endoscopic intervention 4, 1

If Nocturnal Polyuria is Confirmed (>33% output at night)

• Evaluate for cardiovascular disease, sleep apnea, diabetes, and medication effects (particularly diuretics) 4, 3, 7
• Implement fluid restriction in evening hours 1, 3, 7
• Address timing of diuretic medications if applicable 3
• Consider desmopressin 50 µg daily if idiopathic nocturnal polyuria persists after treating underlying conditions 7

If Overactive Bladder Pattern is Confirmed (Small frequent voids with urgency)

• Ensure PVR is low (<150 mL) before initiating anticholinergic therapy 1
• Start behavioral modifications: bladder training, fluid management, avoiding bladder irritants 4, 1, 3
• If behavioral therapy fails, consider antimuscarinic agents (e.g., oxybutynin) or beta-3 agonist (mirabegron) 4, 1
• Do not prescribe antimuscarinics without measuring PVR first, as men with elevated baseline PVR risk acute urinary retention 1

Critical Pitfalls to Avoid

• Do not dismiss resolved hematuria: Even though bleeding stopped 3 days ago, the recent hematuria in context of severe irritative symptoms warrants complete evaluation to exclude infection, incomplete resection, or other pathology 5, 6
• Do not assume symptoms are "normal post-TURP recovery": At 1 month, severe nocturia (7-10 times) represents pathology requiring investigation, not expected healing 4, 3
• Do not start anticholinergics empirically: Always measure PVR first to avoid precipitating acute urinary retention 1
• Do not overlook systemic causes: Nocturia is multifactorial and often driven by cardiovascular, renal, endocrine, or sleep disorders rather than bladder pathology alone 4, 3

Indications for Urgent Urology Referral

Refer immediately if any of the following are present:

• Recurrent or persistent hematuria 5, 6
• Elevated PVR with suspected urethral stricture or bladder neck contracture 4, 1
• Severe obstruction (Qmax <10 mL/second if uroflowmetry available) 1, 2
• Neurological findings affecting bladder function 1, 2
• Failure to improve with conservative management after 4-12 weeks 1, 2