Hematuria, BPH & Prostate (Clinical)
From painless hematuria to PSA, pick the right scan, scope, and drug
Hematuria: confirm, then image and scope
Confirm with microscopy. Microscopic hematuria is 3 or more RBCs per high-power field on urine microscopy. The dipstick detects heme, not cells, so a positive dipstick always needs microscopy.
| Cause | Dipstick heme | RBCs on microscopy |
|---|---|---|
| True hematuria | Positive | ≥3 per hpf |
| Myoglobinuria or hemoglobinuria (rhabdomyolysis, hemolysis) | Positive | None |
| Pigments (beets, rifampin, phenazopyridine) | Negative | None |
Sort out the benign and the glomerular. Treat a UTI and repeat the urinalysis afterward; consider menstruation, vigorous exercise, and recent instrumentation. Dysmorphic RBCs, RBC casts, or proteinuria point to a glomerular source and a nephrology evaluation. Anticoagulation does not explain hematuria; these patients still need a full workup.
Painless gross hematuria in an adult is urinary tract malignancy until proven otherwise, even if it clears on its own.
- Confirm with microscopyRule out myoglobin and hemoglobin.
- CT urographyImages the upper tracts and renal parenchyma.
- CystoscopyInspects the bladder and urethra.
- Urine cytologyAdjunct for high-grade cells.
CT urography plus cystoscopy covers the whole urothelium from kidney to urethra. The same pair evaluates high-risk microscopic hematuria (older age, smoking, occupational exposures); lower-risk microscopic hematuria is evaluated less intensively, often with renal ultrasound instead of CT.
Bladder cancer
Risk factors. Cigarette smoking is the leading risk factor, followed by aromatic amines and aniline dyes (dye, rubber, and leather work) and cyclophosphamide. Presentation is painless hematuria, often intermittent.
Histology. Urothelial (transitional cell) carcinoma is most common. Schistosoma haematobium causes squamous cell carcinoma through chronic bladder irritation.
Diagnosis and treatment. Cystoscopy with transurethral resection of the bladder tumor (TURBT) both diagnoses and stages; the specimen must include detrusor muscle to judge invasion. Non-muscle-invasive disease is treated with TURBT plus intravesical BCG, with surveillance cystoscopy because recurrence is common. Muscle-invasive disease generally requires radical cystectomy, usually after neoadjuvant cisplatin-based chemotherapy.
Cyclophosphamide's metabolite acrolein causes both hemorrhagic cystitis and bladder cancer; mesna binds acrolein and protects the bladder.
BPH, acute retention, and TURP
BPH. Hyperplasia of the transition (periurethral) zone causes lower urinary tract symptoms: hesitancy, weak stream, nocturia, frequency, and incomplete emptying. Digital rectal exam shows a smooth, symmetrically enlarged, rubbery prostate. The International Prostate Symptom Score (IPSS) grades severity and tracks response. BPH is not a precursor of cancer.
| Feature | α1-blocker | 5-α-reductase inhibitor |
|---|---|---|
| Examples | Tamsulosin, terazosin | Finasteride, dutasteride |
| Mechanism | Relaxes prostatic and bladder-neck smooth muscle | Blocks testosterone → DHT, shrinking the gland |
| Onset | Days: fastest relief | 6–12 months |
| Best for | Any bothersome symptoms | Large glands |
| PSA | No effect | Lowered by about 50% |
| Adverse effects | Orthostatic hypotension, intraoperative floppy iris syndrome | Decreased libido, erectile dysfunction; teratogenic |
Because finasteride halves PSA, double the measured PSA in a man taking it before interpreting cancer risk. Uroselective tamsulosin causes less orthostasis than terazosin; warn patients before cataract surgery.
TURP. Transurethral resection of the prostate is definitive for BPH refractory to medication or with complications: urinary retention, recurrent UTI, bladder stones, hydronephrosis, or recurrent gross hematuria. Retrograde ejaculation is a common long-term effect.
TURP syndrome is dilutional hyponatremia from absorption of hypotonic glycine irrigant through opened venous sinuses: confusion, visual disturbances, and hypertension from volume overload. Resection with saline irrigation lowers the risk.
Acute urinary retention. Sudden inability to void, suprapubic pain, and a palpable distended bladder. Immediate bladder catheterization relieves it. Common precipitants are BPH, anticholinergic or opioid medications (including sedating antihistamines taken for allergies), the postoperative state, and neurogenic causes. Starting an α-blocker before a voiding trial improves success; recurrent retention despite therapy is an indication for TURP.
Prostatitis, PSA screening, and prostate cancer
| Feature | BPH | Acute bacterial prostatitis | Prostate cancer |
|---|---|---|---|
| Zone | Transition | Whole gland | Peripheral |
| DRE | Smooth, symmetric, rubbery | Exquisitely tender, boggy | Hard nodule |
| Symptoms | Lower urinary tract symptoms | Fever, dysuria, pelvic pain | Often none; later bone pain |
| Management | α-blocker, 5-ARI, TURP | Fluoroquinolone or TMP-SMX for weeks | Surveillance, surgery, radiation, or androgen deprivation (plus an androgen receptor pathway inhibitor if metastatic) |
Acute bacterial prostatitis. Escherichia coli is the usual pathogen. Avoid vigorous prostate massage, which risks bacteremia. Treat with a fluoroquinolone or trimethoprim-sulfamethoxazole for a prolonged course, since these penetrate prostatic tissue.
PSA screening. Screening is individualized: shared decision-making for men 55–69 (USPSTF grade C) and not routine after age 70. PSA rises with cancer but also with BPH, prostatitis, recent ejaculation, and instrumentation, which limits specificity.
Diagnosis. Prostate adenocarcinoma arises in the peripheral zone, so a hard nodule may be felt on DRE. An abnormal DRE or elevated PSA leads to MRI and transrectal ultrasound-guided biopsy; the Gleason score (grade group) grades aggressiveness. Metastases to bone, often the lumbar spine via the vertebral venous plexus, are osteoblastic (sclerotic), unlike most lytic metastases, causing back pain and elevated alkaline phosphatase.
Treatment. Localized disease is managed with active surveillance when low-risk, or radical prostatectomy or radiation when higher-risk (erectile dysfunction and incontinence are the main surgical costs). Metastatic hormone-sensitive disease is treated with androgen deprivation plus an androgen receptor pathway inhibitor (abiraterone, enzalutamide, apalutamide, or darolutamide), with or without docetaxel; ADT alone is no longer enough. The GnRH agonist leuprolide, given continuously, first stimulates and then downregulates GnRH receptors, so testosterone flares initially; pair it with an antiandrogen such as bicalutamide started first, or use the GnRH antagonist degarelix, which causes no flare.
A testosterone flare in a man with vertebral metastases can worsen bone pain or precipitate spinal cord compression; always block it.