A 54-year-old woman comes to the physician with blood in the urine for a week. It initially occurred once daily, but the frequency increased to twice daily yesterday. The patient has a history of diabetes, osteoarthritis in her knees, and menopause 5 years ago. Her medications include daily metformin and ibuprofen as needed. She has a 30-pack-year smoking history and drinks 1 or 2 beers daily. Her mother had a history of kidney stones and died of breast cancer. She lives with her husband, and her last sexual encounter was approximately 10 days ago. Vital signs are within normal limits. Examination shows no abnormalities. Which of the following is the most appropriate next step in management of this patient?

Question

A 54-year-old woman comes to the physician with blood in the urine for a week.  It initially occurred once daily, but the frequency increased to twice daily yesterday.  The patient has a history of diabetes, osteoarthritis in her knees, and menopause 5 years ago.  Her medications include daily metformin and ibuprofen as needed.  She has a 30-pack-year smoking history and drinks 1 or 2 beers daily.  Her mother had a history of kidney stones and died of breast cancer.  She lives with her husband, and her last sexual encounter was approximately 10 days ago.  Vital signs are within normal limits.  Examination shows no abnormalities.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c092_cfdd_8f63_eff1386650e0_MD0005_00 Gross hematuria (ie, macroscopic or visible) may be due to renal (eg, glomerulonephritis, infection), ureteral (eg, nephrolithiasis), bladder (eg, cystitis, malignancy), or urethral (eg, urethritis, prostatitis) etiologies. In the absence of trauma or suspected nephrolithiasis, the first step in evaluating hematuria is obtaining a urinalysis (UA) and urine culture. A UA confirms the presence of hematuria and can differentiate between infectious, glomerular, and extraglomerular causes. Patients with UA findings suggestive of infection and positive urine culture results or symptoms of urinary infection (eg, dysuria, increased urgency, frequency) should receive a course of antibiotics. Patients with UA findings suggestive of glomerular etiologies for hematuria (eg, proteinuria, red cell casts, dysmorphic red cells) require evaluation for renal causes, including possible renal ultrasound, 24-hour urine studies, serological studies, and eventual renal biopsy (Choices B and C). (Choices A and E) If the etiology of hematuria remains unclear, patients should undergo further imaging (CT urography preferred), and those with risk factors (eg, age >35, smoking history, chronic analgesic abuse, pelvic irradiation, chemical exposure) for urologic malignancy in particular should be referred to a urologist for likely cystoscopy. Educational objective: The first step in evaluating hematuria is a urinalysis and urine culture. Urinalysis confirms the presence of hematuria and can differentiate between infectious, glomerular, and extraglomerular causes. References: Assessment of hematuria. (http://www.ncbi.nlm.nih.gov/pubmed/21095418)

A 54-Year-Old Woman Comes to the Physician with Blood in the Urine