A 73-year-old man is referred to the Urology Clinic with a 3-month history of voiding  symptoms. He finds he has intermittent poor stream and hesitancy when passing urine. He denies any weight loss, fatigue or night sweats and any other urinary symptoms. He is a retired factory worker. His GP had detected an enlarged prostate and a mildly raised prostate-specific antigen 3 months ago and diagnosed him with benign prostatic hypertrophy. He has been taking tamsulosin since but his symptoms are unchanged. His urine dipstick in clinic today is positive for blood.

Which of the following is the best next step in the management of this patient?

Options:
explanation: This patient has haematuria with voiding lower urinary tract symptoms. He should therefore be investigated for malignancy in a dedicated one-stop clinic in the first instance. Transurethral resection of the prostate is performed for benign prostatic hypertrophy (BPH) with symptoms recalcitrant to optimum medical therapy (usually a combination of finasteride and tamsulosin). Therefore, it is not appropriate to refer the patient for this at this stage, where the diagnosis remains uncertain, and the BPH treatment is not yet optimised.
name: Refer for transurethral resection of the prostate
label: b
answer: no
explanation: This would be the investigation of choice if evaluating for metastatic spread of confirmed cancer. It is done further down the line once a malignancy is diagnosed. In the first instance, the patient needs to be reviewed in the one-stop haematuria service, where biopsies may be taken if a lesion is identified to clinch the diagnosis.
name: CT chest, abdomen and pelvis
label: e
answer: no
explanation: The presence of voiding lower urinary tract symptoms and microscopic haematuria and the patient's age and occupational history (factory work, with potential exposure to dyes and rubber) should raise suspicion of bladder cancer. Prostate cancer may also present in a similar way. Patients in the one-stop Haematuria Clinic are thoroughly evaluated for a malignant cause of their symptoms, including flexible cystoscopy to evaluate the bladder and prostate, CT or ultrasound scanning of the urinary tree, bloods (such as for the prostate-specific antigen) and urine dipstick testing.
name: Refer to one-stop Haematuria Clinic
label: a
answer: yes
explanation: This patient has a mildly raised PSA and has been diagnosed with BPH. This does not rule out prostate cancer; however, the patient's symptoms can certainly be explained by the presence of a prostatic malignancy but this is less likely given the presence of microscopic haematuria and the history of factory work. Referral to a one-stop haematuria service is the first step in the management of this presentation due to the presence of haematuria, which requires a dedicated set of investigations. An MRI prostate may be requested further down the line if there is concern that there is prostate cancer if no explanation for his symptoms are identified during the one-stop service or as a first-line investigation for suspected prostate cancer.
name: MRI prostate
label: d
answer: no
explanation: Prostate-specific antigen (PSA) has high sensitivity but low specificity for prostate cancer. It can be raised in other conditions, such as benign prostatic hypertrophy; thus, alone it cannot be used to diagnose prostate cancer. Furthermore, a negative PSA does not rule out malignancy of the prostate or elsewhere in the urinary tract. Given the continuation of this patient's urinary symptoms after pharmacological management and the presence of haematuria, malignancy should be ruled out in a dedicated one-stop Haematuria Clinic.
name: Repeat prostate-specific antigen
label: c
answer: no

Correct answer: a


Learning point: In patients over 50 with urinary symptoms and haematuria, a referral to the haematuria clinic is required for evaluation of potential bladder or prostate cancer.