Urology for the Internist: the Latest on Management of Asymptomatic Hematuria and BPH, and Prostate Cancer Risk Assessment
Updates in the management of asymptomatic hematuria, benign prostatic hyperplasia (BPH), and the assessment of prostate cancer risk were provided by Jesse Mills, MD, Director, The Men’s Clinic at the University of California, Los Angeles.
Hematuria
Common causes of gross hematuria include urinary tract infection (UTI), passing a kidney stone, and transitional cell carcinoma. Women with gross hematuria have a statistically significant delay in the diagnosis of bladder cancer as they are often treated with antibiotics more frequently than men for presumed UTI.
Episodes of gross hematuria require cystoscopy, computed tomographyâurogram, and urine cytology. All cigarette smokers and people with significant environmental exposures who present with gross hematuria require a full work-up because they are a high-risk group.
Microhematuria is defined as >3 red blood cells (RBCs) per high-powered field. “We want a couple of urine samples to confirm that this is the case,” he said. The evaluation for microhematuria is not as easy as that for gross hematuria. It’s often a “nonevent,” he said. The work-up is the same for patients on anticlotting medications.
First treat gynecologic or infectious causes of the microhematuria, and then repeat the urinalysis after the acute issue is resolved.
When microhematuria is confirmed, stratify risk. If a person is high risk, “at least offer them a work-up at that first visit, and let them know what that entails,” he said. If the patient is a nonsmoker and has no significant chemical exposures, engage in shared decision-making and suggest an immediate urologic evaluation or repeat urinalysis in 6 months. If microhematuria is persistent (6 months), restratify the patient as intermediate to high risk and proceed with cystoscopy and upper tract imaging.
Any one of the following criteria constitutes high risk for urothelial cancer: women or men ≥60 years, smoking history >30 pack years, >25 RBCs/high-powered field on a single urinalysis, and a history of gross hematuria. Smoking is the biggest risk factor for transitional cell carcinoma. Additional risk factors are irritative lower urinary tract symptoms (LUTS), prior pelvic radiation, a history of chemotherapy, family history of urothelial cancer or Lynch syndrome, occupational exposure to benzene chemicals or aromatic amines, and a chronic indwelling foreign body in the urinary tract.
About 90% of men 45 to 80 years old suffer from LUTS secondary to benign prostatic hyperplasia (BPH). Obstructive symptoms include straining, intermittency, hesitancy, and incomplete bladder emptying.
Benign prostatic hyperplasia
Although not life threatening, BPH/LUTS can have significant impacts on quality of life. Frequent trips to the restroom at night can set patients up for falls, leading to a cascade of health risks.
In the evaluation of BPH, the American Urological Association (AUA) symptom score, usually performed by a urologist, is a 30-point scale with a higher score associated with more severe LUTS. Perform a urinalysis to rule out infection as the most common cause of urgency/frequency). Flow rate and a postvoid residual are usually checked by a urologist.
“If a guy has an elevated postvoid residual, he’s obstructed, and if he’s obstructed, you’re going to find problems with renal failure potentially, bladder stones, and infections,” he said.
Alpha blockers (alfuzosin, terazosin, tamsulosin, doxazosin, silodosin) can work to relieve symptoms of BPH within hours to weeks. Relaxation of the prostate and bladder neck can lead to an improvement in flow; however, retrograde ejaculation is a common side effect. Avoid alpha blockers in men who are planning to undergo cataract surgery. Postural hypotension can occur with any alpha blocker, less so with tamsulosin.
5-alpha reductase inhibitors (finasteride, dutasteride) may take months to be fully effective. These agents work by decreasing the size of the gland, so they are usually selected in men with prostate glands >40 g. Sexual side effects include decreased libido and erectile dysfunction. 5-alpha reductase inhibitors reduce levels of prostate-specific antigen (PSA) in half after 6 months of use. If PSA doesn’t fall while on a 5-alpha reductase inhibitor, it may be an indication of prostate cancer.
Daily PDE5 inhibitors are useful for men with concomitant BPH and erectile dysfunction. They work by relaxing the intrinsic smooth muscle at the bladder neck and prostatic smooth muscle, thereby easing the outflow of urine. PDE5 inhibitors should be avoided in men who take nitrates for chest pain.
Indications for surgery in men with BPH are bladder stones, recurrent UTIs, recurrent hematuria, renal insufficiency secondary to BPH, and urinary retention. Surgical options (ie, UroLift, Rezum, transurethral resection of the prostate, laser prostatectomy, Holmium laser enucleation of the prostate) are associated with minimal sexual side effects for men who wish to preserve antegrade ejaculation.
Prostate cancer risk assessment
Informed decision-making is the key to prostate cancer risk assessment, said Dr. Mills.
Most men won’t die from prostate cancer, and the side effects of treatment are not minimal (erectile dysfunction, urinary incontinence, and radiation cystitis and proctitis). Even with refined delivery of radiation and refined surgical approaches, including robotic prostatectomy, the complication rate is still significant.
The American College of Physicians recommends that clinicians inform men between the ages of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer.1 It states that the decision to screen for prostate cancer is based on the PSA test, a discussion of the benefits and harms of screening, the patient’s general health and life expectancy, and patient preferences. Average-risk men younger than 50 years, men older than 69 years, or men with a life expectancy less than 10 to 15 years are not recommended to be screened for prostate cancer.
The 2013 AUA guideline2 states that men 55 years and older should be offered prostate cancer risk assessment after an informed discussion on the risks and benefits of screening. Men with a strong family history of prostate cancer can be offered screening 10 years earlier. Do not offer screening to men who do not express interest in screening if you feel they understand risks of not screening.
Imaging may soon become standard of care in prostate cancer screening. Advances in prostate imaging have allowed for better selection of patients for biopsies and better risk stratification for active surveillance versus intervention. Molecular markers are also making inroads into prostate cancer risk assessment and detection.
Disclosure
Boston Scientific, Endo, Antares
References
- Qaseem A, Barry MJ, Denberg TD, Owens DK, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians. Ann Intern Med 2013;158:761-9.
- Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA guideline. J Urol 2013;190:419-26.