A 67-year-old man comes to the office due to 2 weeks of intermittent blood in the urine. He has had no pain, urgency, dysuria, frequency, urethral discharge, or nocturia. The bleeding is present throughout micturition. The patient has a history of coronary artery disease, hypertension, and hyperlipidemia. He has smoked a pack of cigarettes daily for 40 years. He is sexually active. Temperature is 36.9 C (98.4 F), blood pressure is 120/80 mm Hg, pulse is 78/min, and respirations are 16/min. Abdomen is soft and nontender with no masses; bowel sounds are normal. Rectal examination shows an enlarged prostate with no tenderness, asymmetry, or induration. Urinalysis shows 50 red blood cells/hpf; there are no leukocytes, casts, or dysmorphic erythrocytes. Urine cytology shows no abnormal cells. Which of the following is the most appropriate next step in evaluation of this patient?

Question

A 67-year-old man comes to the office due to 2 weeks of intermittent blood in the urine.  He has had no pain, urgency, dysuria, frequency, urethral discharge, or nocturia.  The bleeding is present throughout micturition.  The patient has a history of coronary artery disease, hypertension, and hyperlipidemia.  He has smoked a pack of cigarettes daily for 40 years.  He is sexually active.  Temperature is 36.9 C (98.4 F), blood pressure is 120/80 mm Hg, pulse is 78/min, and respirations are 16/min.  Abdomen is soft and nontender with no masses; bowel sounds are normal.  Rectal examination shows an enlarged prostate with no tenderness, asymmetry, or induration.  Urinalysis shows >50 red blood cells/hpf; there are no leukocytes, casts, or dysmorphic erythrocytes.  Urine cytology shows no abnormal cells.  Which of the following is the most appropriate next step in evaluation of this patient?

Quizplus · Accepted Answer

11ec25c8_d10e_fda3_bc81_f92c208bcd23_MD0003_00 This older patient with a 40-pack-year smoking history has painless, gross hematuria throughout micturition, raising strong suspicion for bladder cancer, the most common malignancy of the urinary tract. Most cases occur due to malignant transformation of the urothelium in response to chronic carcinogen exposure (eg, tobacco smoke, industrial chemicals). Because tumor growth is associated with the formation of friable new blood vessels, bleeding into the urinary tract is common and often results in painless hematuria that lasts throughout micturition (tumors in the bladder neck occasionally present with only terminal hematuria). The workup of gross hematuria begins with urinalysis to confirm the diagnosis (>3 red blood cells/hpf) and to evaluate for common underlying causes, such as urinary tract infection (eg, pyuria, bacteriuria) and glomerulonephritis (eg, red blood cell casts, dysmorphic erythrocytes). Patients who have no clear cause of hematuria and are age >40 require urgent evaluation for urinary tract malignancy; the first tests of choice are generally cystoscopy (to visualize the bladder wall and biopsy/resect suspicious lesions) and CT urography (to visualize the kidney and to evaluate for metastases). Although urine cytology is often performed as part of the evaluation for hematuria, it has low sensitivity (<35%) and cannot be relied on to rule out bladder or kidney cancer. (Choice A) Abdominal ultrasound is not routinely used in the evaluation of hematuria because it frequently misses small bladder masses and cannot evaluate tumor depth, extension to surrounding tissues, or nodal spread. (Choice C) Prostate-specific antigen level can aid in the diagnosis of prostate cancer, which is usually asymptomatic and is found during routine digital rectal examination (eg, prostatic nodule) or prostate-specific antigen testing. Hematuria is uncommon because most prostate cancers grow in the periphery of the gland rather than in the central, periurethral zone. (Choice D) Painless hematuria in an adult age >40 must be evaluated urgently with cystoscopy because delays in diagnosis of bladder or kidney cancer are associated with poor prognosis. (Choice E) Urine culture can diagnose urinary tract infection, which usually causes irritative bladder symptoms (eg, dysuria, frequency), pyuria, and bacteriuria. This patient has painless hematuria with no leukocytes in his urine, making an infection unlikely. Educational objective: Bladder cancer often presents with painless hematuria that lasts throughout micturition in an adult age >40. Urinalysis should be performed to confirm hematuria (>3 red blood cells/hpf) and to rule out infection/glomerulonephritis. Those with no clear cause for hematuria require urgent evaluation with cystoscopy to visualize the bladder for lesions.

A 67-Year-Old Man Comes to the Office Due to 2