Management Plan for Male with Hematuria
1. Initial Assessment and History
- Presenting Symptoms: Determine if the hematuria is visible (macroscopic) or non-visible (microscopic) and if there are accompanying symptoms, such as dysuria, flank pain, or fever, which could indicate infection or other underlying causes.
- Medical History: Assess for risk factors, including age (increased risk of malignancy in older males), smoking history, occupational exposure to chemicals, recent strenuous exercise, recent trauma, or a history of renal/urological diseases.
- Medication Review: Identify any medications that might cause or exacerbate hematuria (e.g., anticoagulants, NSAIDs).
2. Physical Examination
- Consider performing a general examination, including blood pressure, abdominal examination, and focused genitourinary assessment, checking for tenderness over the flanks or suprapubic region, which could suggest a possible urinary tract infection (UTI) or stone disease.
3. Initial Investigations
- Urine Dipstick: Perform an initial urine dipstick test to check for red blood cells, nitrites, leukocytes, and protein. This can help differentiate between infection and other causes of hematuria.
- Urine Sample for Microscopy, Culture, and Sensitivity (MCS): Send a midstream urine (MSU) sample to the lab. Microscopy can confirm the presence of red blood cells, while culture and sensitivity testing can guide antibiotic therapy if an infection is present.
4. Blood Tests
- Basic Blood Panel: Consider a Full blood count (FBC), renal function tests (e.g., urea and creatinine), and possibly clotting studies if there is suspicion of a bleeding disorder.
- PSA (Prostate-Specific Antigen): If the patient is at risk for prostate pathology, particularly in older men, a PSA may be considered after discussion.
5. Imaging
- Ultrasound or CT Urogram: Consider imaging if there are persistent symptoms, signs of kidney stones, or risk factors for malignancy. Non-visible hematuria with a high risk of malignancy often warrants imaging to assess for renal, ureteral, or bladder pathology.
6. Antibiotic Management
- If urine dipstick and MCS indicate a UTI, treat according to culture sensitivity results. In cases where empirical antibiotic treatment is necessary before MCS results return:
- Empirical Antibiotics (e.g., Nitrofurantoin, Trimethoprim): Follow local antibiotic guidelines and CKS/Best Practice recommendations.
- For men with symptoms suggestive of upper UTI (e.g., pyelonephritis), consider broader spectrum agents (e.g., ciprofloxacin or co-amoxiclav) if safe and appropriate.
- Adjust Based on Sensitivity Results: Modify antibiotic therapy based on culture sensitivity results to ensure effective and targeted treatment.
7. Referral and Follow-up
- Referral to Urology: If hematuria is persistent, visible, or unexplained after initial investigation, or if there are high-risk factors for malignancy, refer to urology for further assessment (e.g., cystoscopy).
- Follow-up: Arrange a follow-up appointment to review urine MCS results, confirm resolution of hematuria, and reassess if symptoms persist or worsen.
Key Points
- Urine MCS is essential for diagnosis, guiding antibiotic choice, and ruling out other causes.
- Antibiotic therapy should be guided by local resistance patterns and adjusted based on culture sensitivity results.
- Persistent or unexplained hematuria may indicate a malignancy risk, warranting further investigation and possible urology referral.
This plan aligns with guidance from CKS and BMJ Best Practice and considers appropriate steps for managing hematuria in a male patient while focusing on infection control and assessment for potential underlying causes.