A 53-year-old man comes to the office due to occasional red urine for the last 3 months. He states that his urine stream appears normal initially but turns red by the end of voiding. He has also noticed small clots in his urine. The patient has not had any fever, edema, flank pain, or weight loss. Medical history is significant for chronic back pain. He currently smokes a pack of cigarettes daily but does not use alcohol. His temperature is 37.5 C (99.5 F) and blood pressure is 140/90 mm Hg. Physical examination is within normal limits. Urinalysis is positive only for blood. Which of the following is the most likely cause of this patient's symptoms?

Question

A 53-year-old man comes to the office due to occasional red urine for the last 3 months.  He states that his urine stream appears normal initially but turns red by the end of voiding.  He has also noticed small clots in his urine.  The patient has not had any fever, edema, flank pain, or weight loss.  Medical history is significant for chronic back pain.  He currently smokes a pack of cigarettes daily but does not use alcohol.  His temperature is 37.5 C (99.5 F) and blood pressure is 140/90 mm Hg.  Physical examination is within normal limits.  Urinalysis is positive only for blood.  Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d110_ab56_bc81_ab06fa6e6e7d_MD0003_00 Gross (ie, visible or macroscopic) hematuria can be classified based on the stage of voiding at which bleeding predominates: Initial hematuria is characterized by blood at the beginning of the voiding cycle and often reflects a urethral source. Total hematuria is characterized by blood during the entire voiding cycle and can reflect bleeding from anywhere in the urinary tract (eg, bladder, kidneys). Terminal hematuria is characterized by blood at the end of voiding cycle and often suggests bleeding from the prostate, bladder neck or trigone, or posterior urethra. Urothelial (bladder) cancer is associated with blood vessel formation and often presents with painless, total hematuria; however, terminal hematuria can also be seen if the cancer originates from the bladder neck or trigone. This patient with several risk factors for urothelial cancer (age >40, sex, smoking) has terminal hematuria with clots (which suggest a nonglomerular-and usually lower urinary tract-source of bleeding). Therefore, he should undergo cystoscopy to evaluate for bladder cancer and other sources of terminal hematuria. Delays in diagnosis of bladder cancer are associated with poor prognosis. cystoscopy (Choice B) Glomerular diseases can cause nephritic syndrome with microscopic or gross hematuria. Patients can also present with total hematuria. However, clots are unusual in glomerular disease, and urinalysis frequently shows red blood cell casts and may show proteinuria. (Choice C) Nephrolithiasis can cause hematuria. However, stones usually present with flank or groin pain, depending on the location of the stone. (Choice D) Polycystic kidney disease (PCKD) is the leading heritable cause of renal disease in adults. Although it can cause hypertension, it usually presents as abdominal or flank pain with microscopic or gross total hematuria and, occasionally, a bulky mass on abdominal examination. The patient does not have any of these features, and his elevated blood pressure is more likely due to essential hypertension than to PCKD. (Choice E) Urethritis or urethral injury (eg, Foley catheterization) typically manifests as initial hematuria. (Choice F) All urinary tract infections (pyelonephritis, cystitis, urethritis) may present with microscopic or gross hematuria. However, pyelonephritis usually presents with flank pain and systemic illness (eg, fever, nausea, vomiting); cystitis and urethritis present with irritative voiding symptoms (eg, dysuria, urinary frequency, hesitancy). Educational objective: Initial hematuria suggests urethral damage, terminal hematuria indicates bladder or prostatic damage, and total hematuria reflects damage anywhere in the urinary tract. Clots are not usually seen with renal causes of hematuria (eg, glomerular diseases).

A 53-Year-Old Man Comes to the Office Due to Occasional