What is the management approach for a patient with hematuria and an enlarged prostate gland with calcification, but no other symptoms?

Management of Hematuria with Enlarged Prostate and Calcification

This patient requires urgent urologic evaluation with cystoscopy and upper tract imaging (CT urography) regardless of the prostatic findings, as hematuria—even without other symptoms—carries a significant risk of malignancy that must be excluded before attributing bleeding to benign prostatic disease. 1, 2

Why Prostatic Calcification Does Not Explain Away Hematuria

• Prostatic calcifications are extremely common age-related findings, occurring in 7-70% of middle-aged and older men, and are usually asymptomatic and incidental. 3
• The presence of benign prostatic hyperplasia (BPH) with calcifications does not exclude concurrent malignancy, and hematuria attributed to prostatic causes must be proven through appropriate evaluation—not assumed. 2, 3
• Gross hematuria carries a 30-40% risk of malignancy, while microscopic hematuria carries a 0.5-5% overall cancer risk (higher in certain subgroups), making urologic evaluation mandatory. 2, 4

Mandatory Complete Urologic Evaluation

Before attributing hematuria to the prostate, you must exclude bladder cancer, kidney cancer, and upper tract urothelial carcinoma through:

Upper Tract Imaging

• Multiphasic CT urography is the preferred imaging modality to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis. 2, 5
• This includes unenhanced, nephrographic phase, and excretory phase images to comprehensively evaluate kidneys, collecting systems, ureters, and bladder. 2

Lower Tract Evaluation

• Cystoscopy is mandatory to visualize bladder mucosa, urethra, and ureteral orifices for transitional cell carcinoma—the most frequently diagnosed malignancy in hematuria cases. 2, 5
• Flexible cystoscopy is preferred as it causes less pain with equivalent or superior diagnostic accuracy compared to rigid cystoscopy. 2

Laboratory Testing

• Confirm true hematuria with microscopic urinalysis showing ≥3 RBCs per high-power field on properly collected specimens. 2, 5
• Obtain serum creatinine to assess renal function. 2, 5
• Check for proteinuria and examine urinary sediment for dysmorphic RBCs or red cell casts to exclude glomerular disease. 2

When to Consider Nephrology Referral

Refer to nephrology if any of the following are present:

• Significant proteinuria (protein-to-creatinine ratio >0.2 g/g or >500-1000 mg/24 hours). 2
• Dysmorphic RBCs >80% or red cell casts (pathognomonic for glomerular disease). 2
• Elevated serum creatinine or declining renal function. 2
• Tea-colored or cola-colored urine suggesting glomerular bleeding. 2

Only After Malignancy is Excluded: Consider Prostatic Hematuria Treatment

If the complete urologic evaluation is negative and hematuria is definitively attributed to prostatic bleeding:

Medical Management

• Finasteride 5 mg daily (a 5-alpha-reductase inhibitor) has been shown to successfully treat prostatic hematuria caused by BPH by reducing prostate vascularity and volume. 6, 7
• Finasteride reduces the risk of acute urinary retention by 67% and BPH-related surgery by 64% in men with enlarged prostates. 6

Minimally Invasive Options for Refractory Cases

• Selective arterial prostatic embolization using interventional radiologic techniques can rapidly stop persistent prostatic hematuria. 7
• Transurethral resection or vaporization of the prostate may be required if medical management and embolization fail. 7

Critical Pitfalls to Avoid

• Never attribute hematuria to BPH or prostatic calcifications without first excluding malignancy—this is a dangerous assumption that can delay cancer diagnosis and worsen outcomes. 2, 8
• Do not defer evaluation because the patient is asymptomatic—the absence of other symptoms does not reduce cancer risk. 2, 4
• Delays in diagnosis beyond 9 months from first hematuria presentation are associated with worse cancer-specific survival in bladder cancer patients. 2
• Anticoagulation or antiplatelet therapy does not cause hematuria—these medications may unmask underlying pathology that requires investigation. 2

Follow-Up Protocol if Initial Evaluation is Negative

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit. 2
• Immediate re-evaluation is warranted if: gross hematuria develops, significant increase in microscopic hematuria occurs, new urologic symptoms appear, or development of hypertension/proteinuria. 2
• After two consecutive negative annual urinalyses, no further testing for asymptomatic microhematuria is necessary. 2