In a 67‑year‑old man with painless hematuria, benign prostatic hyperplasia and a normal intravenous pyelogram, what is the next diagnostic investigation?

Cystoscopy Is the Next Diagnostic Test

In a 67-year-old man with painless hematuria, benign prostatic hyperplasia, and a normal intravenous pyelogram, cystoscopy is the mandatory next step to exclude bladder cancer, which is the most common malignancy presenting with hematuria in this age group. 1, 2

Why Cystoscopy Is Essential

• Gross hematuria carries a 30-40% risk of malignancy and requires urgent urologic evaluation with cystoscopy and upper tract imaging, regardless of whether bleeding is self-limited or a benign cause like BPH is suspected. 2

• Cystoscopy has very high diagnostic accuracy for bladder cancer, with sensitivity ranging from 87-100% and negative predictive values between 98-100%, exceeding the diagnostic value of any other imaging test. 1

• Flexible cystoscopy is the preferred modality because it causes less pain and has equivalent or superior diagnostic accuracy compared to rigid cystoscopy, while allowing direct visualization of the bladder mucosa, urethra, and ureteral orifices. 2

• BPH does not exclude concurrent malignancy—gross hematuria from BPH must be proven to be of prostatic etiology through appropriate evaluation, and bladder cancer can coexist with benign prostatic disease. 2, 3

Why the Other Options Are Inadequate

CT Abdomen (Option B)

• While multiphasic CT urography is the preferred imaging for upper tract evaluation, the IV pyelogram has already assessed the upper urinary tract (kidneys, ureters, collecting systems). 2
• Imaging alone cannot replace cystoscopy for bladder evaluation—bladder cancer requires direct visualization and cannot be reliably excluded by CT. 1, 2

Ultrasound (Option C)

• Renal ultrasound alone is insufficient for comprehensive hematuria evaluation and has limited ability to detect bladder pathology compared to cystoscopy. 2
• Ultrasound is appropriate for low-risk patients or pediatric populations, but this 67-year-old man with gross hematuria is automatically high-risk. 2

Prostate Biopsy (Option D)

• Prostate biopsy is not indicated in the initial evaluation of hematuria, even with known BPH. 2
• The digital rectal exam showed no suspicious features, and hematuria must first be proven to be of prostatic origin before attributing it to prostate pathology. 3
• Never perform prostatic massage or biopsy during acute evaluation of hematuria until infection and malignancy are excluded. 3

Critical Clinical Reasoning

• Age ≥60 years is a high-risk feature that mandates complete urologic evaluation with cystoscopy regardless of other factors. 2

• Painless hematuria is the classic presentation of bladder cancer, and delays in diagnosis beyond 9 months are associated with worse cancer-specific survival. 2

• The normal IV pyelogram excludes upper tract pathology (renal masses, ureteral tumors, stones), but the bladder—the most common site of urothelial malignancy—remains unevaluated. 2

• BPH is a common benign cause of hematuria in older men, but it is a diagnosis of exclusion that can only be made after malignancy is ruled out through cystoscopy. 2, 4, 5

Common Pitfalls to Avoid

• Never ignore gross hematuria, even if self-limited—30-40% malignancy risk mandates urgent urologic referral. 2

• Do not attribute hematuria to BPH without cystoscopic confirmation—malignancy must be excluded first. 2, 3

• Do not delay cystoscopy while pursuing additional imaging—bladder visualization is mandatory and cannot be replaced by any radiologic study. 1, 2

• Do not assume a normal upper tract study (IV pyelogram) completes the hematuria evaluation—the bladder must still be directly examined. 2