A 74-year-old man comes to the office due to urinary frequency over the last 2 months. He wakes up to use the bathroom several times during the night. He also has had mild straining during urination. Over the last few weeks, he has had 2 episodes of bloody urine that cleared spontaneously. The patient had right knee replacement for severe osteoarthritis 7 years ago. His father died of colon cancer. He has a 30-pack-year smoking history but quit 15 years ago. Rectal examination shows an enlarged and smooth prostate with no nodules, and normal rectal sphincter tone. Serum creatinine is 0.8 mg/dL and prostate-specific antigen level is 3.8 ng/mL (normal

Question

A 74-year-old man comes to the office due to urinary frequency over the last 2 months.  He wakes up to use the bathroom several times during the night.  He also has had mild straining during urination.  Over the last few weeks, he has had 2 episodes of bloody urine that cleared spontaneously.  The patient had right knee replacement for severe osteoarthritis 7 years ago.  His father died of colon cancer.  He has a 30-pack-year smoking history but quit 15 years ago.  Rectal examination shows an enlarged and smooth prostate with no nodules, and normal rectal sphincter tone.  Serum creatinine is 0.8 mg/dL and prostate-specific antigen level is 3.8 ng/mL (normal <4 ng/mL).  Urinalysis shows 0-1 white blood cells/hpf and 3-5 red blood cells/hpf, with no proteinuria, bacteriuria, casts, or dysmorphic red blood cells.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d0f1_b181_bc81_e11cf3bced15_MD0003_00 This patient has benign prostatic hyperplasia (BPH), which usually affects men age >50, can cause lower urinary tract symptoms (eg, increased urinary frequency, hesitation, dribbling, nocturia) and a feeling of incomplete voiding, and is associated with a smooth and symmetrically enlarged prostate without nodules. However, he also has gross (eg, episodes of bloody urine) and microscopic (eg, >3 red blood cells/hpf) hematuria. Causes of microscopic hematuria include renal (eg, renal cell cancer, IgA nephropathy), ureteral (eg, stricture, stone), bladder (eg, cancer, cystitis), and prostate/urethral (eg, BPH, prostate cancer, urethritis) abnormalities. In the absence of evidence of glomerular disease (eg, dysmorphic red blood cells) or infection (eg, pyuria, bacteriuria), cystoscopy is recommended for all patients who have gross hematuria or for those with microscopic hematuria associated with other risk factors for bladder cancer, such as this patient. Cigarette smoking is the most important risk factor for bladder cancer. Although smoking cessation decreases this risk, patients still have a higher risk than nonsmokers even up to 20 years after smoking cessation. Other risk factors include certain occupational exposures (eg, painters, metal workers), chronic cystitis, iatrogenic causes (eg, cyclophosphamide), and pelvic radiation exposure. Although BPH can cause hematuria, this patient should first be evaluated with cystoscopy to exclude bladder cancer. If negative, he can receive BPH treatment with alpha adrenergic antagonists (eg, terazosin, tamsulosin) with or without 5-alpha reductase inhibitors (eg, finasteride) (Choice B). (Choice C) Prostate biopsy is generally indicated to evaluate for prostate cancer. Although prostate cancer can present with obstructive voiding symptoms and hematuria, rectal examination usually shows an asymmetrically enlarged prostate that can be firm or have nodules. In this patient with a normal PSA and benign features on prostate examination, biopsy is not needed. (Choice D) Urine culture is generally recommended to rule out infections (eg, cystitis) as the cause of microscopic hematuria. Cystitis usually presents with acute onset of hematuria, lower urinary tract symptoms, and abnormal urinalysis (eg, pyuria, red blood cells). However, this patient's symptom duration (2 months) and absence of significant pyuria or bacteriuria make this less likely. (Choice E) Maximal urinary flow rate testing can also diagnose BPH. Flow rates >15 mL/sec usually exclude significant bladder outlet obstruction. This is considered an optional test for most patients. Educational objective: Cystoscopy is recommended for patients with gross hematuria or with microscopic hematuria and other risk factors for bladder cancer. Risk factors for bladder cancer include cigarette smoking, certain occupational exposures (eg, painters, metal workers), chronic cystitis, iatrogenic causes (eg, cyclophosphamide), and pelvic radiation exposure. References: Indication of cystoscopy in patients with asymptomatic microscopic haematuria. (http://www.ncbi.nlm.nih.gov/pubmed/10757271) Diagnosis and treatment of bladder cancer: how can we improve? (http://www.ncbi.nlm.nih.gov/pubmed/22691896)

A 74-Year-Old Man Comes to the Office Due to Urinary