What is the appropriate initial workup for a 57‑year‑old male with hematuria (clots in urine) and painful ejaculation who underwent transurethral resection of the prostate (TURP) two years ago?

Initial Workup for a 57-Year-Old Male with Clots in Urine and Painful Ejaculation, Status Post TURP

This patient requires urgent urologic evaluation with cystoscopy and upper tract imaging within 24–48 hours because gross hematuria with clots carries a 30–40% risk of underlying malignancy, regardless of his prior TURP. 1

Immediate Diagnostic Steps

1. Confirm True Hematuria and Assess Hemodynamic Status

• Verify visible blood in urine and exclude pseudohematuria from medications, foods, or menstrual contamination 1
• Assess vital signs immediately to determine hemodynamic stability; patients with ongoing bleeding and instability require resuscitation targeting hemoglobin >7 g/dL while avoiding fluid overload 1
• Obtain microscopic urinalysis confirming ≥3 RBCs per high-power field on a properly collected specimen 1

2. Essential Laboratory Evaluation

• Complete blood count to assess for anemia from blood loss 1
• Serum creatinine and BUN to evaluate renal function 1
• Coagulation studies if the patient is on anticoagulation or has bleeding risk factors 1
• Urine culture before initiating any antibiotics, as infection does not exclude malignancy and may mask cancer 1
• Voided urine cytology given his age >40 years and high-risk presentation with gross hematuria 1

3. Risk Stratification

This patient is automatically high-risk based on multiple factors 1:

• Age 57 years (>40 years threshold)
• Gross hematuria with clots
• Prior TURP (history of urologic surgery)
• Painful ejaculation (irritative symptoms without documented infection)

Mandatory Imaging and Endoscopic Evaluation

Upper Tract Imaging

• Multiphasic CT urography is the preferred modality, including unenhanced, nephrographic, and excretory phases to detect renal cell carcinoma, transitional cell carcinoma, and urolithiasis with 96% sensitivity and 99% specificity 1
• If CT is contraindicated due to renal insufficiency or contrast allergy, use MR urography or renal ultrasound with retrograde pyelography 1

Lower Tract Evaluation

• Flexible cystoscopy is mandatory and should not be delayed while awaiting imaging results 1
• Cystoscopy provides direct visualization of the bladder mucosa, urethra, and ureteral orifices—imaging alone cannot exclude bladder cancer 1
• Flexible cystoscopy is preferred over rigid cystoscopy because it causes less pain while providing equivalent or superior diagnostic accuracy 1
• In patients with prior TURP, cystoscopy is particularly important to evaluate the resection site, bladder neck, and prostatic urethra for recurrent disease or complications 2, 3

Differential Diagnosis Considerations

Post-TURP Complications (2 Years Out)

• Bladder neck contracture or urethral stricture can cause irritative symptoms and hematuria 2, 3
• Delayed bleeding from the prostatic fossa is possible but less likely at 2 years 3
• Recurrent benign prostatic hyperplasia causing venous bleeding 2

Malignancy (Primary Concern)

• Bladder transitional cell carcinoma is the most common malignancy causing hematuria and accounts for 30–40% of gross hematuria cases 1
• Upper tract urothelial carcinoma of the renal pelvis or ureter 1
• Prostate cancer involving the prostatic urethra or bladder neck, particularly given painful ejaculation 2
• Hematuria can precede bladder cancer diagnosis by many years, making evaluation essential even with prior negative workup 1

Other Urologic Causes

• Urolithiasis causing obstruction and bleeding 1
• Urinary tract infection with hemorrhagic cystitis, though this must be proven and does not exclude concurrent malignancy 1
• Prostatic urethral pathology including prostatic cysts or ejaculatory duct obstruction causing hemospermia 2

Evaluation of Painful Ejaculation

Hemospermia Workup (If Blood in Ejaculate Confirmed)

• Transrectal ultrasound (TRUS) is the first-line imaging for persistent hemospermia in men ≥40 years, detecting abnormalities in 82–95% of cases including calcifications, cysts, or masses in the prostate, seminal vesicles, or ejaculatory ducts 2
• Pelvic MRI should be used if TRUS is inconclusive or negative, as it provides superior soft tissue contrast for evaluating the seminal tract 2
• Prostate-specific antigen (PSA) level must be checked in all men ≥40 years to screen for prostate cancer 2

Prostatic Urethral Evaluation

• During cystoscopy, carefully examine the prostatic urethra, verumontanum, and ejaculatory duct orifices for obstruction, stricture, calculi, or masses 2
• Consider TUR biopsy of the prostatic urethra if abnormalities are visualized, as bladder transitional cell carcinoma involves the prostate in 12–40% of patients 4

Critical Pitfalls to Avoid

• Never dismiss gross hematuria as benign even if self-limited or attributed to prior TURP—the 30–40% malignancy risk mandates urgent evaluation 1
• Do not attribute hematuria to anticoagulation or antiplatelet therapy without completing full urologic workup, as these medications may unmask underlying pathology but do not cause hematuria 1
• Do not delay cystoscopy while awaiting imaging results—bladder cancer requires direct visualization and cannot be excluded by CT alone 1
• Do not prescribe empiric antibiotics for presumed UTI without urine culture in a patient with gross hematuria and risk factors, as this delays cancer diagnosis 1
• Do not assume painful ejaculation is benign prostatitis without excluding malignancy and structural abnormalities 2
• Imaging alone is insufficient—even with normal CT urography, cystoscopy remains mandatory because bladder cancer is the most frequently diagnosed malignancy in hematuria cases 2, 1

Follow-Up Based on Initial Findings

If Malignancy Detected

• Urgent referral for transurethral resection of bladder tumor (TURBT) with bimanual examination under anesthesia if bladder lesion identified 2
• Adequate muscle sampling is essential during TURBT to accurately stage disease 2, 4
• Diagnostic delays >9 months are associated with 34% increase in cancer-specific mortality 1

If Initial Workup Negative

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit 1
• Immediate re-evaluation warranted if gross hematuria recurs, microscopic hematuria increases significantly, new urologic symptoms develop, or hypertension/proteinuria emerges 1
• Consider repeat comprehensive evaluation within 3–5 years for persistent hematuria in high-risk patients 1