How should I evaluate a 45-year-old man with gross hematuria and a history of transurethral resection of the prostate (TURP) performed two years ago?

Evaluation of a 45-Year-Old Male with Gross Hematuria and Prior TURP

This patient requires urgent urologic referral for cystoscopy and upper tract imaging (CT urography) regardless of the prior TURP, as gross hematuria carries a 30-40% risk of malignancy and mandates immediate evaluation even when bleeding appears self-limited. 1, 2

Immediate Risk Stratification

This 45-year-old male is automatically high-risk based on multiple factors:

• Gross (visible) hematuria alone carries a 30-40% malignancy risk and requires urgent evaluation 1, 2
• Age ≥40 years is a high-risk criterion mandating full urologic work-up 1
• History of TURP does not exclude concurrent malignancy—bladder cancer can develop independently of BPH 3

Critical Diagnostic Steps (Within 24-48 Hours)

1. Confirm True Hematuria

• Obtain microscopic urinalysis showing ≥3 RBCs per high-power field on a properly collected clean-catch specimen 1
• Measure serum creatinine to assess renal function 1, 4

2. Mandatory Cystoscopy

• Flexible cystoscopy is essential and cannot be deferred—bladder cancer accounts for 30-40% of gross hematuria cases and cannot be excluded by imaging alone 1, 2
• Flexible cystoscopy provides equivalent or superior diagnostic accuracy to rigid cystoscopy with less patient discomfort 1, 4
• Direct visualization of bladder mucosa, urethra, and ureteral orifices is required 3

3. Upper Tract Imaging

• Multiphasic CT urography (unenhanced, nephrographic, and excretory phases) is the preferred modality with 96% sensitivity and 99% specificity for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis 1, 4
• If CT is contraindicated, use MR urography or renal ultrasound with retrograde pyelography 1

4. Adjunctive Testing

• Voided urine cytology should be obtained given his age and gross hematuria to detect high-grade urothelial carcinomas 1, 4
• Urine culture if infection is suspected (obtain before antibiotics) 1

Differential Diagnosis Beyond Post-TURP Bleeding

While post-TURP hematuria can occur, you must exclude malignancy first:

Urologic Malignancies (30-40% of gross hematuria)

• Bladder cancer (transitional cell carcinoma)—most common malignancy in hematuria patients 3, 1
• Renal cell carcinoma 1
• Upper tract urothelial carcinoma 1

Post-TURP Complications

• Late hemorrhage can occur up to 3 weeks post-TURP, with bleeding directly related to resected tissue weight and operative duration 5
• Delayed bleeding typically resolves within 3 weeks but can persist 5
• However, hematuria 2 years post-TURP is NOT explained by the procedure itself and requires full malignancy work-up 6, 5

Other Urologic Causes

• Urolithiasis (kidney or bladder stones) 1
• Benign prostatic hyperplasia with prostatic bleeding—but this does not exclude concurrent malignancy 1
• Urinary tract infection 1

Glomerular Causes (Less Likely with Gross Hematuria)

• If urinalysis shows >80% dysmorphic RBCs or red cell casts, consider nephrology referral in addition to urologic evaluation 1, 4
• Tea-colored or cola-colored urine suggests glomerular source 1

Common Pitfalls to Avoid

• Never attribute gross hematuria to prior TURP without complete evaluation—delays in diagnosis beyond 9 months are associated with 34% increase in cancer-specific mortality 2
• Do not assume anticoagulation or antiplatelet therapy is the cause—these medications may unmask underlying pathology but do not cause hematuria 1, 2
• Do not delay evaluation even if bleeding is self-limited—intermittent bleeding is characteristic of bladder cancer 1
• Do not rely on imaging alone—cystoscopy is mandatory because bladder cancer requires direct visualization 1, 2

Follow-Up Protocol if Initial Work-Up is Negative

If cystoscopy and CT urography are negative:

• Repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring 1, 4
• Immediate re-evaluation if: recurrent gross hematuria, marked increase in microscopic hematuria, new urologic symptoms, or development of hypertension/proteinuria 1
• After two consecutive negative annual urinalyses, further testing can be discontinued 1

Bottom Line

Refer urgently to urology today for cystoscopy and CT urography. The 2-year interval since TURP does not explain current gross hematuria, and the 30-40% malignancy risk mandates immediate complete evaluation regardless of the prior surgical history. 1, 2