A 67-year-old man comes to the physician with hematuria. Three days ago, he experienced an episode of gross hematuria that resolved spontaneously. There was no associated dysuria, fever, chills, or flank pain. He did not pass any blood clots in his urine. He denies bleeding or bruising elsewhere except for very rare oozing from the gums after brushing his teeth. The patient has no history of kidney stones or recent trauma. He awakens twice at night to urinate and has noticed a decrease in the size and force of his urine stream over the past 2 years.
His past medical history is significant for hypertension, hyperlipidemia, and coronary artery disease. He underwent placement of 2 drug-eluting coronary artery stents after a non-ST elevation myocardial infarction 3 months ago. His current medications include low-dose aspirin, clopidogrel, lisinopril, metoprolol, and rosuvastatin.
Physical examination is unremarkable.
Laboratory results are as follows:

Urine culture is negative.
What is the best next step in the management of this patient?

Question

A 67-year-old man comes to the physician with hematuria.  Three days ago, he experienced an episode of gross hematuria that resolved spontaneously.  There was no associated dysuria, fever, chills, or flank pain.  He did not pass any blood clots in his urine.  He denies bleeding or bruising elsewhere except for very rare oozing from the gums after brushing his teeth.  The patient has no history of kidney stones or recent trauma.  He awakens twice at night to urinate and has noticed a decrease in the size and force of his urine stream over the past 2 years.
His past medical history is significant for hypertension, hyperlipidemia, and coronary artery disease.  He underwent placement of 2 drug-eluting coronary artery stents after a non-ST elevation myocardial infarction 3 months ago.  His current medications include low-dose aspirin, clopidogrel, lisinopril, metoprolol, and rosuvastatin.
Physical examination is unremarkable.
Laboratory results are as follows:

Urine culture is negative.
What is the best next step in the management of this patient?

Quizplus · Accepted Answer

Hematuria in patients taking dual antiplatelet or anticoagulant therapy is uncommon and is usually due to underlying genitourinary tract abnormalities. This patient has no evidence of urinary tract infection, and trace protein is unlikely to represent significant glomerular disease. He should be evaluated further with CT urography followed by cystoscopy to rule out underlying malignancy. CT urography helps evaluate both the renal parenchyma and collecting system. Although his nocturia may be a sign of benign prostatic hyperplasia, malignancies such as bladder and prostate carcinomas should be excluded. Cystoscopy is a minimally invasive procedure and complications are extremely rare. Most patients do not have to discontinue dual antiplatelet therapy and are advised that they may have some minor spotting or bleeding post procedure. This patient had recent percutaneous coronary intervention with placement of drug-eluting stents. Aspirin or clopidogrel should not be discontinued due to his increased risk of stent thrombosis (Choices B and C). Guidelines indicate continuation of dual antiplatelet therapy for ~6-12 months after drug-eluting stent placement. (Choice D) This patient has no history of liver disease and is not on anticoagulation therapy. Hematuria due to a spontaneous coagulation abnormality is uncommon and routine testing is not needed. (Choice E) All patients with gross hematuria who have no evidence of glomerular disease or urinary tract infection should undergo further evaluation. Educational objective: Hematuria is uncommon in patients on dual antiplatelet therapy or anticoagulants. Patients with risk factors for malignancy should be evaluated with CT urography followed by cystoscopy to rule out genitourinary tract abnormalities. __________ References: Perioperative management of patients with coronary stents. (http://www.ncbi.nlm.nih.gov/pubmed/17543633) Safety of short-term discontinuation of antiplatelet therapy in patients with drug-eluting stents. (http://www.ncbi.nlm.nih.gov/pubmed/19289638) Coronary stents and noncardiac surgery. (http://www.ncbi.nlm.nih.gov/pubmed/17938292)

A 67-Year-Old Man Comes to the Physician with Hematuria