A 65-year-old man comes to the office for a follow-up evaluation of hematuria. He underwent evaluation for an insurance policy and was told that he had blood in his urine. He has never observed any blood in his urine; however, he has noticed a progressively weaker urinary stream over the past several years and often gets up to urinate at least twice each night. He has no history of flank or abdominal pain, and has never passed a kidney stone or had urinary tract infection. He has smoked more than one pack of cigarettes daily for 40 years. He recently retired from many years of employment in the dye industry.
He has been diagnosed with moderate chronic obstructive lung disease, benign prostatic hypertrophy, degenerative joint disease, and hypertension. His current medications consist of an inhaler containing a beta adrenergic agonist, several over-the-counter NSAIDs, and lisinopril.
His blood pressure is 140/90 mm Hg, pulse is 84/min, and respirations are 20/min. Physical examination findings are compatible with moderate chronic obstructive lung disease. A urinalysis performed in the office shows a positive dipstick and 3-5/hpf RBCs. Subsequently, 2 additional urinalyses are performed; RBCs are 1-2/hpf on the first and 5-10/hpf on the second urinalysis. Urine cytology is negative for malignant cells on 3 occasions. A CT scan of the kidneys is within normal limits. A urine culture is negative.
The patient's laboratory studies reveal:

Which of the following is the most appropriate next step in management?

Question

A 65-year-old man comes to the office for a follow-up evaluation of hematuria.  He underwent evaluation for an insurance policy and was told that he had blood in his urine.  He has never observed any blood in his urine; however, he has noticed a progressively weaker urinary stream over the past several years and often gets up to urinate at least twice each night.  He has no history of flank or abdominal pain, and has never passed a kidney stone or had urinary tract infection.  He has smoked more than one pack of cigarettes daily for 40 years.  He recently retired from many years of employment in the dye industry.
He has been diagnosed with moderate chronic obstructive lung disease, benign prostatic hypertrophy, degenerative joint disease, and hypertension.  His current medications consist of an inhaler containing a beta adrenergic agonist, several over-the-counter NSAIDs, and lisinopril.
His blood pressure is 140/90 mm Hg, pulse is 84/min, and respirations are 20/min.  Physical examination findings are compatible with moderate chronic obstructive lung disease.  A urinalysis performed in the office shows a positive dipstick and 3-5/hpf RBCs.  Subsequently, 2 additional urinalyses are performed; RBCs are 1-2/hpf on the first and 5-10/hpf on the second urinalysis.  Urine cytology is negative for malignant cells on 3 occasions.  A CT scan of the kidneys is within normal limits.  A urine culture is negative.
The patient's laboratory studies reveal:

Which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

11ec193a_98f1_70a5_853d_f9c9a65772e0_MD0002_00 This patient has microscopic hematuria (defined as RBCs > 3/hpf) along with several risk factors for bladder cancer (ie, age, gender, ethnicity, cigarette smoking history, and possible exposure to chemicals associated with bladder cancer). Chemicals associated with bladder cancer development include aromatic amines, arsenic, and other chemicals involved in the manufacture of dyes, rubber, leather, and textiles. As outlined in the figure, this patient had asymptomatic dipstick hematuria with microhematuria seen on subsequent urinalysis. Given his bladder cancer risk and presence of microhematuria on 1of the 2 additional urine samples, imaging and urine cytology were performed. Because results of these studies were both negative, the next step would be cystoscopy to evaluate for bladder malignancy. (Choice A) Although the hematuria observed is low grade, this patient's risk profile for bladder cancer is high, and timely visualization of the bladder is appropriate to potentially diagnose an early stage cancer. (Choice B) Coagulation disorders rarely present as hematuria and are almost always associated with an abnormality within the genitourinary tract (eg, stone and tumor). This patient takes agents that may decrease platelet function (ie, NSAIDs), but coagulation studies would be low yield in this patient. (Choice D) With the CT scan showing no cause for the hematuria, MRI would be of very low diagnostic yield. (Choice E) Benign prostatic hyperplasia (BPH) can cause gross hematuria, usually at either initiation or termination of micturition. Although the mechanism of hematuria in BPH remains unclear, prominent neovascularization can occur and lead to visualization of enlarged veins in the prostatic urethra on cystoscopy. In this high-risk patient, bladder cancer should initially be excluded. Educational objective: Advancing age, male sex, Caucasian ethnicity, cigarette smoking, exposure to selected chemicals, chronic bladder inflammation, and a family history of cancer are risk factors for bladder cancer. Hematuria in a patient with risk factors should promote a timely evaluation for cancer with imaging, urine cytology, and cystoscopy. __________ References: The significance of adult hematuria: 1,000 hematuria evaluations and risk-benefit and cost-effectiveness analysis (http://www.ncbi.nlm.nih.gov/pubmed/2492350) Association of hematuria on microscopic urinalysis and risk of urinary tract cancer. (http://www.ncbi.nlm.nih.gov/pubmed/21419446)

A 65-Year-Old Man Comes to the Office for a Follow-Up