A 65-year-old man comes to the office due to 3 days of progressive right flank pain. He also notes 4 weeks of dysuria and urinary frequency. The patient has a history of coronary artery disease and hypertension. His father died from prostate cancer. Temperature is 37.1 C (98.8 F), blood pressure is 130/86 mm Hg, pulse is 82/min, and respirations are 16/min. The abdomen is soft and nontender. No suprapubic tenderness is present, but there is mild right-sided costovertebral angle tenderness. The external genitalia are normal in appearance, and there is no penile discharge. Rectal examination shows mildly enlarged prostate without nodules or tenderness. Urinalysis results are as follows: Urine gram stain is negative, and urine culture does not grow any organisms. Abdominal ultrasound reveals right-sided hydronephrosis and a normal left-sided kidney and ureter. Which of the following is the most appropriate next step?

Question

A 65-year-old man comes to the office due to 3 days of progressive right flank pain.  He also notes 4 weeks of dysuria and urinary frequency.  The patient has a history of coronary artery disease and hypertension.  His father died from prostate cancer.  Temperature is 37.1 C (98.8 F), blood pressure is 130/86 mm Hg, pulse is 82/min, and respirations are 16/min.  The abdomen is soft and nontender.  No suprapubic tenderness is present, but there is mild right-sided costovertebral angle tenderness.  The external genitalia are normal in appearance, and there is no penile discharge.  Rectal examination shows mildly enlarged prostate without nodules or tenderness.  Urinalysis results are as follows:  Urine gram stain is negative, and urine culture does not grow any organisms.  Abdominal ultrasound reveals right-sided hydronephrosis and a normal left-sided kidney and ureter.  Which of the following is the most appropriate next step?

Quizplus · Accepted Answer

Explanation: This patient's voiding symptoms (eg, dysuria, frequency), hematuria, and acute right-sided flank pain with hydronephrosis raise strong suspicion for bladder cancer. In the United States, most cases arise from the bladder surface epithelium (urothelium) due to chronic exposure to chemical carcinogens in the environment or in cigarette smoke. Older adults are most often affected and typically have ≥1 of the following: Hematuria: tumor growth drives the formation of new blood vessels that may bleed, leading to gross or microscopic hematuria; it is classically painless and present throughout voiding Hydronephrosis: bladder outlet or ureter obstruction by the tumor leads to hydronephrosis, which can be associated with flank pain and acute renal insufficiency (eg, elevated creatinine), as seen in this patient Voiding symptoms: bladder tumors can reduce bladder capacity, cause detrusor muscle hyperactivity, or result in bladder neck/urethra obstruction, leading to voiding manifestations such as nocturia, frequency, urgency, and dysuria Adults age >40 who have painless hematuria require prompt investigation for bladder cancer when no evidence of infection (eg, dysuria, pyuria, bacteriuria), glomerulonephritis (eg, red blood cell casts, dysmorphic red blood cells), or nephrolith are present. The gold-standard initial test is urinary cystoscopy, which allows direct visualization of the bladder wall and biopsy of suspicious masses. Abdominal CT is then generally necessary for staging. (Choices B and G) Older men with benign prostatic hyperplasia often have hematuria and chronic voiding symptoms and can sometimes develop acute urinary tract obstruction, which requires decompression with a Foley catheter. However, prostatic urinary obstruction usually causes bilateral (not unilateral) hydronephrosis because it is below the level of the bladder. Unilateral hydronephrosis is usually decompressed with ureteral stent (not Foley catheter). Patients with benign prostatic hyperplasia who have recurrent urinary obstruction or significant lower urinary symptoms sometimes require transurethral prostate resection. (Choices C and D) Prostate biopsy and prostate-specific antigen help evaluate for prostatic cancer, which is often (but not always) associated with a prostatic nodule on examination. Hematuria and acute urinary retention are rare in prostate cancer because most tumors form in the periphery of the prostate, not in the periurethral zone. (Choice E) Patients with unexplained, painless hematuria require urgent evaluation for bladder and kidney cancer. Furthermore, individuals with hydronephrosis require urgent decompression in order to prevent kidney damage. (Choice F) Bilateral testicular ultrasound is indicated for testicular cancer, which usually presents in young males (age 15-35) with unilateral testicular nodule or swelling. Hematuria and hydronephrosis are uncommon. Educational objective: Bladder cancer is common in older adults and often presents with hematuria, voiding symptoms (eg, dysuria, frequency), and/or hydronephrosis with flank pain. Urgent cystoscopy is required to visualize the bladder wall and to biopsy suspicious masses.

A 65-Year-Old Man Comes to the Office Due to 3