A 59-year-old man comes to the office due to a month of dysuria, urinary urgency, and frequency. Over the past few days, he has also had dull, nonradiating suprapubic pain. He has never had similar symptoms before. The patient has a history of obesity, type 2 diabetes mellitus, gastroesophageal reflux disease, and major depression. He has smoked a pack of cigarettes daily for 40 years and does not use alcohol or drugs. Vital signs are within normal limits. The abdomen is soft with no organomegaly. Mild suprapubic tenderness is present. Rectal examination reveals a smooth, firm enlargement of the prostate with no tenderness, induration, or asymmetry. Laboratory results are as follows. Which of the following is the most likely explanation for this patient's symptoms?

Question

A 59-year-old man comes to the office due to a month of dysuria, urinary urgency, and frequency.  Over the past few days, he has also had dull, nonradiating suprapubic pain.  He has never had similar symptoms before.  The patient has a history of obesity, type 2 diabetes mellitus, gastroesophageal reflux disease, and major depression.  He has smoked a pack of cigarettes daily for 40 years and does not use alcohol or drugs.  Vital signs are within normal limits.  The abdomen is soft with no organomegaly.  Mild suprapubic tenderness is present.  Rectal examination reveals a smooth, firm enlargement of the prostate with no tenderness, induration, or asymmetry.  Laboratory results are as follows.  Which of the following is the most likely explanation for this patient's symptoms?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d2ae_06bb_bc81_7107ddedad2f_MD0003_00 This patient's smoking history, subacute voiding symptoms (eg, dysuria, urgency, frequency), suprapubic pain, and hematuria likely indicate bladder cancer. Most cases arise in adults age >40 who have chronic exposure to chemical carcinogens such as cigarette smoke or industrial chemicals. Common manifestations include: Hematuria: Tumors are fed by new, friable blood vessels that often bleed into the urinary tract. Hematuria tends to occur throughout micturition and may be gross (visible) or microscopic. Voiding symptoms: Tumors often protrude into the bladder and reduce bladder volume or cause detrusor overactivity, leading to subacute/chronic voiding symptoms such as dysuria, frequency, and urgency. Although bladder cancer is often associated with painless hematuria (no pain during micturition), some patients with bladder cancer have dysuria as part of their voiding symptoms. Suprapubic pain: This usually indicates a more advanced tumor that has penetrated the muscle and invaded the surrounding soft tissue or nerves. Urinalysis is generally the first test of choice to confirm hematuria (≥3 RBCs/hpf) and to rule out other common causes of hematuria such as infection (eg, significant pyuria, bacteriuria, leukocyte esterase) or glomerulonephritis (eg, red cell casts, dysmorphic RBCs). Cystoscopy with biopsy and urinary tract imaging (eg, CT urogram) is then required if no clear cause is evident. (Choice B) Although bladder infections frequently cause voiding symptoms, suprapubic pain, and hematuria, urinalysis usually shows significant pyuria (eg, >10 leukocytes/hpf). In addition, most cases arise acutely, not over 4 weeks. (Choice C) Chronic bacterial prostatitis often causes recurrent symptoms of urinary tract infection (eg, dysuria, frequency, urgency) that improve with short courses of antibiotic therapy but then recur. However, urinalysis often shows pyuria and bacteriuria, and hematuria is unlikely. (Choice D) Detrusor overactivity can lead to voiding symptoms (eg, nocturia, frequency, urgency) and urinary incontinence. However, hematuria would be atypical. (Choice E) Prostate cancer is generally asymptomatic and discovered on prostatic examination (nodule) or with prostate-specific antigen testing. Because prostate cancer usually grows in the periphery of the gland, hematuria and voiding symptoms are uncommon (as the tumor does not impinge upon the central periurethral area). (Choice F) Renal cell carcinoma often presents with painless hematuria; some patients also have flank pain and a palpable mass. However, voiding symptoms and suprapubic pain are uncommon. (Choice G) Urethral stricture can cause voiding symptoms and urinary retention with subsequent suprapubic pain. However, most patients have decreased urinary stream, and hematuria is uncommon. Educational objective: Bladder cancer often causes hematuria, voiding symptoms (eg, dysuria, urgency, frequency), and/or suprapubic pain. Patients who have no clear source (eg, cystitis) for these symptoms require urgent workup with cystoscopy.

A 59-Year-Old Man Comes to the Office Due to a Month