Question :

Prostate issues, Blood in urine and further management

Dear Ask The Doctor:
My Father in law just had a Ct scan for hematuria without pain. He has had a previous TURP at least 10 years ago or more and his PSA is WNL currently. I am a nurse but because this is not my specialty I have some questions. I understand the PSA can still be WNL after a TURP and not be normal. His prostate is boggy upon exam, he has had blood in his urine on and off for over 4 months. He had a prior cyst removed over 4 years ago from his bladder but frm what I understand it was not biopsied. His Ct Scan results show low density in R hepatic lobe consistent with cyst, low density 5mm in left adrenal gland consistent with adrenal adenoma, low denisty L renal lesion consistent with a cyst, high density within inferior prostate consistent with calcification and low density within the central prostate suggesting a TURP defect. Im concerned with all of these cysts as this now totals 4 in various areas of the pelvic cavity. There is still no explanation of the bleeding unless it is blamed on the renal cysts There is no mention of the bladder at all whch concerns me especially considering the prior bladder cyst and the ct scan says bladder included in exam to base. The only mention is that there is no evidence of filling defect in the bladder. He does have hx of kidney stones and there is one non obstructing .7cm on in the left kidney lower pole. I am very concerned about all of these lesions and whether or not they are truly cystic and benign lesions considering ALL of the medical information provided. What would be your next step and what would you be looking for or monitoring going forward? LynAnn RN

Answer :

Dear Patient: 
You have given me quite a comprehensive history which is helpfull in explaining further. There are a lot of findings which you have mentioned which I will try and explain individually. First coming to the symptom that your father in law has ie hematuria ( blood in urine) and this is caued by many conditions like
1) UTI
2) Renal stones: which he has a history of
3) Renal carcinoma/ bladder carcinoma/ polycystic kidneys
4) BPH/ prostatic carcinoma
5) drugs like rifampin, dyes,
After evaluating the condition I feel my next step would be to carry out a transrectal ultrasound of the prostate to evaluate the condition of the prostate ( because you say it is boggy on palpation) and this would also help analyse the area of calcification present and to rule out any areas of nodule formation . Also repeat the PSA level and if it is in normal range then that essentially rules out a prostatic carcinoma.
The cysts in the liver and kidney are benign and liver and renal adenomas are common and are usually considered as incidental finidings on a CT. The cause of the bleeding as of now seems to point more towards that of kidney stones and thus I would advice a Urine analysis for both stones and infection.
In terms of the bladder since he did have a cyst removed and not biopsied it would be advisable to get an cystoscopy performed to rule out any bladder carcinoma which can also lead to hematuria.
I hope this helps.All the best.

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