A 58-year-old man comes to the office due to urinary symptoms. Over the past year, he has had difficulty initiating urination and a weakened urine stream. He also has frequent nocturnal voiding. The patient has not passed any visible blood clots and has had no dysuria, fever, recent illnesses, or urinary trauma. He has no other medical conditions and takes no medications. Vital signs are within normal limits. Rectal examination reveals a smooth, enlarged prostate with no tenderness to palpation. Prostate-specific antigen is within the normal range. Urinalysis reveals 20-30 red blood cells per high power field and no urinary casts. Cystoscopy is performed and shows increased bladder wall trabeculations with normal appearing mucosa. Which of the following is the most likely cause of this patient's hematuria?

Question

A 58-year-old man comes to the office due to urinary symptoms.  Over the past year, he has had difficulty initiating urination and a weakened urine stream.  He also has frequent nocturnal voiding.  The patient has not passed any visible blood clots and has had no dysuria, fever, recent illnesses, or urinary trauma.  He has no other medical conditions and takes no medications.  Vital signs are within normal limits. Rectal examination reveals a smooth, enlarged prostate with no tenderness to palpation.  Prostate-specific antigen is within the normal range.  Urinalysis reveals 20-30 red blood cells per high power field and no urinary casts.  Cystoscopy is performed and shows increased bladder wall trabeculations with normal appearing mucosa.  Which of the following is the most likely cause of this patient's hematuria?

Quizplus · Accepted Answer

11ec160b_3a2c_36a0_9249_6f47febe85d2_MD0001_00 This patient's urinary hesitancy, weakened urinary stream, and nocturia in the setting of an enlarged, nontender prostate raises strong suspicion for benign prostatic hyperplasia (BPH), a common condition in men age >50. In BPH, stromal and glandular hyperplasia in the periurethral and transitional zone can impinge the urethra, leading to progressive urinary voiding (eg, hesitancy, weakened stream) and storage (eg, nocturia, frequency) symptoms. The diagnosis is generally confirmed when examination reveals a smooth, large, non-tender prostate. Prostate-specific antigen (PSA) can be normal or elevated in BPH, so it is not useful for BPH diagnosis (it is more useful for prostate cancer screening). Microscopic or gross hematuria can sometimes arise in patients with BPH due to the formation of new, friable blood vessels in the area of prostatic hyperplasia. Further examination with cystoscopy is generally warranted to rule out other (potentially life-threatening) causes of hematuria such as bladder cancer and urinary calculi. Cystoscopy in those with BPH often shows increased detrusor wall trabeculations due to detrusor muscle hypertrophy (to generate increased pressure to overcome urethral obstruction). (Choice A) Hematuria is typically caused by urinary tract pathology rather than a systemic bleeding disorder. Furthermore, systemic bleeding disorders are often associated with other sites of mucosal bleeding (eg, nosebleed) or bruising. The presence of lower urinary tract symptoms and prostatic enlargement make BPH more likely. (Choice C) Glomerulonephritis can cause hematuria but is also associated with red blood cell casts. The urine is often described as dark, and the onset is generally more acute (eg, following an upper respiratory infection). (Choice D) Although interstitial cystitis can cause urinary frequency, urgency, and nocturia, it is more common in women and usually presents with suprapubic pain (often worse with bladder filling and better with voiding). In addition, hematuria is uncommon, and cystoscopy is likely to show patchy erythema and petechiae. (Choice E) Bladder cancer often presents with painless hematuria and storage symptoms (eg, frequency, urgency). However, voiding symptoms (eg, hesitancy, decreased force of stream) are less common, and most cases arise in the setting of advanced age, smoking, or chemical/carcinogen exposures in the workplace. Cystoscopy generally reveals a mucosal mass, not increased trabeculations. Educational objective: Benign prostatic hyperplasia (BPH) is associated with stromal and glandular growth in the periurethral and transitional zone of the prostate. The hyperplastic cells are supported by the formation of new blood vessels, which may be friable. Therefore, BPH is often associated with microscopic or gross hematuria. __________ References: Assessment of asymptomatic microscopic hematuria in adults. (http://www.ncbi.nlm.nih.gov/pubmed/24364522)

A 58-Year-Old Man Comes to the Office Due to Urinary