A 68-year-old man comes to the office due to episodes of gross hematuria over the last 3 months. Blood is present throughout micturition. The patient has no abdominal pain, dysuria, urinary frequency, or nocturia. Medical history includes type 2 diabetes mellitus, for which he takes metformin. The patient is retired, lives at home with his wife, and spends most of his free time working in his backyard greenhouse. Prior to retirement, he worked at a rubber manufacturing plant for 35 years. Vital signs are within normal limits. On examination, the abdomen is soft and nontender with no palpable masses. Serum creatinine is 1.1 mg/dL. Which of the following is most likely to be discovered on further workup of this patient's symptoms?

Question

A 68-year-old man comes to the office due to episodes of gross hematuria over the last 3 months.  Blood is present throughout micturition.  The patient has no abdominal pain, dysuria, urinary frequency, or nocturia.  Medical history includes type 2 diabetes mellitus, for which he takes metformin.  The patient is retired, lives at home with his wife, and spends most of his free time working in his backyard greenhouse.  Prior to retirement, he worked at a rubber manufacturing plant for 35 years.  Vital signs are within normal limits.  On examination, the abdomen is soft and nontender with no palpable masses.  Serum creatinine is 1.1 mg/dL.  Which of the following is most likely to be discovered on further workup of this patient's symptoms?

Quizplus · Accepted Answer

11ec160b_3a2e_0b62_9249_cbd2e853b068_MD0001_00 This patient has intermittent, painless gross hematuria. In an older patient, this presentation raises suspicion for urinary tract cancer, especially urothelial (transitional cell) bladder cancer (UBC). The diagnosis of UBC can be confirmed by identifying erythematous sessile, nodular, or papillary lesions on cystoscopy. The malignant epithelial cells are pleomorphic and have hyperchromatic nuclei, an increased nucleus/cytoplasm ratio, and disrupted orientation and polarity (in relation to the basement membrane). Frequent mitotic figures may be present. UBC is most common in patients age >60, with men affected more often than women. Major risk factors include cigarette smoking and occupational exposure to rubber, plastics, aromatic amine-containing dyes, textiles, or leather. Cyclophosphamide therapy (eg, for lymphoma, autoimmune disorders) also increases the risk. In Africa and the Middle East, infection with Schistosoma haematobium is associated with multiple cell types of bladder cancer, including UBC and squamous cell carcinoma. (Choice B) Glomerulonephritis can cause grossly red or tea-colored urine but more commonly causes microscopic hematuria with red cell casts and dysmorphic red blood cells. (Choice C) Interstitial cystitis is characterized by bladder pain, urinary frequency, and dysuria. Gross hematuria is not typical. (Choice D) Autosomal dominant polycystic kidney disease can cause hypertension, hematuria, and renal insufficiency. However, hypertension is usually present by age 40, and this patient has no other suggestive features (eg, renal insufficiency, palpable kidneys). (Choice E) Prostate cancer is typically asymptomatic or discovered on evaluation for lower urinary tract voiding symptoms (eg, decreased force of stream, nocturia). Painless hematuria without voiding symptoms is more suggestive of bladder cancer. (Choice F) Staghorn calculi are large magnesium ammonium phosphate (struvite) stones that fill the renal calyces. Although they may cause hematuria, they are typically seen in patients with recurrent urinary tract infections by urease-producing bacteria (eg, Proteus, Klebsiella). Educational objective: Urothelial (transitional cell) bladder cancer typically affects the elderly and presents with gross hematuria. A history of smoking or occupational exposure to rubber, plastics, aromatic amine-containing dyes, textiles, or leather increases the risk. __________ References: Epidemiology and risk factors of urothelial bladder cancer. (http://www.ncbi.nlm.nih.gov/pubmed/22877502)

A 68-Year-Old Man Comes to the Office Due to Episodes