© The Canadian Journal of Urology™; 21(Supplement 2); June 2014
must be careful, however, if the patient has a negative
urine culture. Even if the patient’s bleeding stops afer
a course of antibiotics, a negative urine culture should
raise the suspicion that the patient may have a bladder
tumor.
Rare causes of hematuria include a ruptured
renal cyst, arteriovenous (AV)-ureteric fistula, or
endometriosis of the bladder.
A minimum work up for patients with significant
microscopic or macroscopic hematuria includes:
• Urinalysis to look for protein and casts, to rule
out a renal cause
• A urine culture and sensitivity test
• Possibly a urine cytology test
• A flat plate x-ray of the abdomen showing
the kidneys, ureter, and bladder (KUB), and an
abdomial ultrasound
• Complete blood count (CBC), electrolytes, and
creatinine blood tests to determine if the patient
needs a blood transfusion or if their kidneys are
affected
• Prothrombin time (PT), international normalized
ratio (INR), and platelet count should be
performed if the patient is taking a blood thinner
or if blood dyscrasia suspected
If a patient has gross hematuria with a negative
culture, or other tests are inconclusive, thenanabdominal
computed tomography (CT) urogram is appropriate.
Referral to a urologist
Patientswith gross or significantmicroscopic hematuria
and a negative urine culture should be referred to a
urologist. The urologist will perform a cystoscopy and
possibly a retrograde pyelogram, as well as any other
tests needed to determine the cause of the hematuria.
Prostate-specific antigen (PSA)
PSA is a serine protease enzyme that is only produced
within the prostate, whichmeans that it is specific to the
prostate. Serine protease, a glycoprotein, is involved in
the liquefaction of seminal coagulum and the release of
motile sperm.
Total PSA
The total PSA test has a 75% sensitivity, but only a
40% specificity for detecting prostate cancer. PSA
is produced by both benign and malignant cells. It
takes a lot of benign prostatic hyperplasia (BPH) to
raise PSA levels, or a little prostate cancer to raise
PSA levels.
Conditions that interfere with the integrity of
prostate cell membranes allow PSA to leak into the
blood. Serum PSA may be elevated in patients who
have prostatitis, a UTI, or prostate cancer, or those
who had recent sexual activity or a recent, vigorous
digital rectal examination (DRE) or recent urethral
instrumentation.
Therefore, do not request a PSA test in the
emergency department if the patient is presenting
with signs and symptoms of acute bacterial prostatitis
or an acute UTI, because it will be artificially elevated.
One should always do a DRE before drawing a blood
sample for a PSA test, or if after a vigorous DRE
wait 30 minutes before drawing blood for a PSA test.
However, a typical DRE should not raise the PSAlevel
significantly.
Controversy about PSA screening tests to detect
prostate cancer
When to do PSA testing to screen for prostate cancer
has been controversial for some time. The controversy
came to a head a few years ago when a US Preventive
Services Task Force (USPSTF) recommendation
discouraged this screening.
2
However, Canadian,
3
American,
4
and European Urological Associations
5
all
recommend regular screening for men over age fifty.
The US Prostate, Lung, Colorectal, and Ovarian
(PLCO) Cancer Screening Trial
6
on which the USPSTF
based its PSA testing recommendations was seriously
flawed. First, the task force did not include a urologist.
More importantly, there was a 52% contamination
rate in the PLCO trial—that is, more than 50% of the
patients had already had a previous PSA, and patients
with high PSAs who required biopsies should have
been excluded from the trial, because theywere already
pre-screened. The trial was designed to assess and
follow only patients who had never had a PSAbefore,
which represents “true” screening.
Table 1 summarizes the European Randomized
Study of Screening for Prostate Cancer (ERSPC), the
Göteborg prostate-cancer screening trial (where there
was a small contamination rate), and the PLCO study.
Age-related PSA
Different approaches have been used to make PSA
testing more specific for prostate cancer. A PSA of 4
ng/mLwas widely accepted as indicating a suspicion
of prostate cancer, and many studies have shown that
this threshold PSA level is accurate for suggesting
possible prostate cancer in men who are 60 and
older. However, serum PSA levels can be elevated
in conditions other than prostate cancer that disturb
the normal architecture of the prostate, including
inflammation of the prostate (prostatitis), inflammation
57
A guide to the management of urologic dilemmas for the primary care physician (PCP)
