A 57-year-old man presents to his physician for his annual examination. He has a history of hypertension, chronic obstructive pulmonary disease (COPD), and benign prostatic hyperplasia (BPH). On examination, there is hyper-resonance to percussion of both lung fields and a diffusely enlarged, nontender prostate on rectal examination. His blood work is unremarkable, but urine studies show 12 RBCs per high power field. There are no dysmorphic RBCs or RBC casts, and there are no other cells or protein. He denies any fevers, flank or groin pain, episodes of gross hematuria, or dysuria. A repeat urinalysis 1 week later confirms the presence of microscopic hematuria, and his urine culture is negative. He elects to undergo further workup with a CT scan of the abdomen and pelvis with and without contrast, which is unremarkable.
What is the next step in management?
A. Measure PSACystoscopy. Microscopic hematuria is defined as ≥3 RBCs per high power field on urine sediment microscopy, and should be confirmed with a repeat study given the high incidence of transient hematuria (which is usually benign but in older patients is still associated with an increased risk of malignancy). (D) Glomerulonephritis is a potential cause of hematuria and may lead to a renal biopsy if suspected, but in this case it is unlikely given that there were no dysmorphic RBCs, RBC casts, or other suggestive findings. In the absence of infection or glomerular disease, urine cytology (to screen for infections and neoplasms) and a CT scan (to screen for nephrolithiasis, renal neoplasms, etc.) should be performed. (C) An IV pyelogram may be used to visualize the urinary tract, but a CT scan is a better imaging modality and was already performed in this case. The next step is therefore cystoscopy, which will help to visualize the bladder for cancer. Remember that in microscopic hematuria, in the absence of an identifiable cause (infection or glomerular disease), all patients should receive radiologic imaging of the urinary tract and cystoscopy.
(A, B) This patient has a history of BPH and consistent findings on examination (diffusely enlarged prostate), making prostate cancer a less likely explanation for this patient’s hematuria. PSA screening may be discussed with the patient in the future, but a cystoscopy needs to be performed next. (F) In the presence of BPH, new fragile blood vessels form and may rupture causing hematuria; however, more serious causes of hematuria still need to be ruled out.