What is the best course of treatment for a patient with stage 3 prostate cancer, a suprapubic (urinary catheter inserted through the abdomen) catheter, and a persistent urinary tract infection (UTI), presenting with hematuria (blood in the urine)?

Management of Hematuria in Stage 3 Prostate Cancer with Suprapubic Catheter and Persistent UTI

In this patient, the hematuria must be assumed to originate from bladder cancer or the prostate cancer itself until proven otherwise, requiring urgent cystoscopy and upper tract imaging regardless of the catheter or UTI, while simultaneously treating the infection with culture-directed antibiotics for no more than 7 days. 1, 2

Immediate Diagnostic Priorities

Rule Out Malignancy First

• Gross hematuria carries a 30-40% malignancy risk and mandates complete urologic evaluation even when other explanations (catheter, UTI, prostate cancer) seem obvious. 2, 3
• Cystoscopy is mandatory to exclude bladder cancer, which is the most common presenting symptom in 32% of bladder cancer cases and can coexist with prostate cancer. 1
• The presence of a catheter does NOT explain away hematuria—catheter-associated hematuria should still prompt consideration of bladder cancer or urinary lithiasis. 1, 4
• In prostate cancer patients who did not undergo radical prostatectomy (stage 3 disease typically managed with radiation/hormones), the prostate cancer itself causes hematuria in 60% of cases, but this is a diagnosis of exclusion. 3

Obtain Upper Tract Imaging

• CT urography (or renal ultrasound/MRI urogram if contrast-contraindicated) is required to evaluate for upper tract urothelial carcinoma, stones, or hydronephrosis. 1
• Upper tract imaging is particularly important given the persistent UTI, as infection-related stones (struvite) can cause both hematuria and recurrent infections. 2

Infection Management

Culture-Directed Antibiotic Therapy

• Obtain urine culture before initiating antibiotics, as catheterized patients have higher rates of antimicrobial resistance. 5
• The IDSA and AUA guidelines recommend treating symptomatic UTI (fever, dysuria, suprapubic pain) for no longer than 7 days, even with the catheter in place. 5
• Do not extend treatment beyond 7 days unless there is delayed clinical response, in which case 10-14 days maximum is appropriate. 5

Catheter Considerations

• The suprapubic catheter should be replaced (not just irrigated) if it has been in place for an extended period, as biofilm formation perpetuates infection and can contribute to bleeding. 1, 4
• Consider whether the patient still requires the suprapubic catheter—if bladder drainage is still needed, suprapubic catheters have lower bacteriuria rates than indwelling urethral catheters but still carry infection risk. 1

Addressing the Hematuria Source

Prostate Cancer as the Culprit

• In stage 3 prostate cancer patients treated non-surgically (radiation/hormones), the cancer itself is the most common cause of gross hematuria (60% of cases). 3
• However, bladder cancer coexists in 38.5% of prostate cancer patients who underwent radical surgery, making cystoscopy non-negotiable. 3
• Median survival after hematuria onset in non-surgically treated prostate cancer patients is only 13 months, indicating this is often a sign of disease progression. 3

Immediate Hemorrhage Control if Severe

• If bleeding is severe enough to cause clot retention or hemodynamic instability, continuous bladder irrigation through the suprapubic catheter is first-line. 6, 7
• Cystoscopy with clot evacuation may be required if conservative measures fail. 6, 7
• Transurethral resection of prostate (TURP) or fulguration of bleeding prostatic tissue is effective in 91.8% of cases managed conservatively, with emergency prostatectomy reserved for refractory cases. 7
• Formalin instillation (1-10% solution) can be used for intractable hemorrhagic cystitis from radiation or tumor, though this requires cystoscopy first to exclude bladder perforation. 6

Follow-Up Protocol After Acute Management

If Malignancy is Excluded

• Repeat urinalysis 6 weeks after treating the UTI and controlling hematuria to confirm resolution. 2
• If hematuria persists (≥3 RBCs/HPF), repeat cystoscopy and imaging are required. 1, 2
• Annual urinalysis at 6,12,24, and 36 months with blood pressure monitoring if hematuria persists after negative workup. 1, 2

If Bladder Cancer is Diagnosed

• Stage and grade determine treatment: non-muscle invasive disease (Ta, T1, Tis) is managed with transurethral resection ± intravesical therapy, while muscle-invasive disease (≥T2) requires radical cystectomy or bladder-preserving chemoradiotherapy. 1

Critical Pitfalls to Avoid

• Never attribute hematuria solely to the catheter, UTI, or anticoagulation without complete urologic evaluation—30-40% of gross hematuria cases harbor malignancy. 1, 2
• Do not delay cystoscopy even if the UTI seems like an obvious explanation—infection and cancer frequently coexist. 1
• Do not treat asymptomatic bacteriuria in catheterized patients, but symptomatic UTI (fever, dysuria, suprapubic pain) requires treatment. 5
• Do not use antibiotics for more than 7 days for uncomplicated cystitis, as this promotes resistance without improving outcomes. 5
• Recognize that hematuria in non-surgically treated prostate cancer portends poor prognosis (median survival 13 months), often indicating disease progression requiring palliative care discussions. 3