A 24-year-old woman comes to the office for evaluation of dysuria and hematuria. For the past 3 days, the patient has had burning with urination and blood-tinged urine. She has had no fever, involuntary loss of urine, or postvoid dribbling. The patient has no bladder pain between voidings. She has had similar episodes for the past 6 months, starting a few days prior to menses. The symptoms usually resolve spontaneously, and she is asymptomatic for a few weeks before symptoms recur. The patient has no other medical conditions and takes no daily medications. Temperature is 36.7 C (98.1 F), blood pressure is 110/80 mm Hg, and pulse is 76/min. BMI is 21 kg/m². The lower abdomen is slightly tender to palpation with no rebound or guarding. There is no costovertebral angle or flank tenderness. On pelvic examination, the bladder is tender to palpation of the anterior vaginal wall. There is no urethral discharge. Urinalysis results are as follows: Urine culture is negative. Which of the following is the most likely diagnosis in this patient?

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11ec25c8_da9a_8848_bc81_3df62791c9c0_MD0003_00 This patient with cyclic dysuria and hematuria associated with menses most likely has endometriosis, the ectopic implantation of endometrial glands and stroma in the abdominopelvic cavity. Although some patients are asymptomatic and diagnosed incidentally, those who are symptomatic often have varying presentations and examination findings that depend on the implant location. implant location This patient likely has deeply infiltrating implants in the bladder; these endometrial implants shed with monthly menses, causing bladder pain and suprapubic tenderness. In addition, patients can have dysuria with associated hematuria and leukocytes on urinalysis due to bladder inflammation. The ectopic endometrial implants and subsequent fibrosis can cause the characteristic anterior vaginal wall tenderness and/or nodularity, as seen in this patient. When the menstrual cycle ends, symptoms classically resolve until the next cycle. Definitive diagnosis of endometriosis is by direct visualization and biopsy during surgical exploration. Conservative treatment includes oral contraceptives and nonsteroidal anti-inflammatory drugs. Surgery can remove visible lesions, but recurrence is common. (Choice B) Interstitial cystitis presents with bladder pain, occasionally with associated white blood cells on urinalysis secondary to inflammation. In contrast to this patient, those with interstitial cystitis typically have pain that is worse with bladder filling and alleviated with bladder emptying. (Choice C) Nephrolithiasis may cause hematuria and white blood cells on urinalysis, but patients typically have colicky pain that radiates from the flank to the pelvis rather than dysuria. This patient has no costovertebral angle or flank tenderness, making this diagnosis less likely. (Choice D) Recurrent urinary tract infections (ie, ≥3 episodes/yr or ≥2/6 months) may present with episodic hematuria and dysuria. However, this diagnosis is highly unlikely in this patient with a negative urine culture. (Choice E) A urethral diverticulum is herniation of the urethral mucosa into surrounding tissue. Although it can cause dysuria, patients usually also have postvoid dribbling, urethral discharge, and an anterior vaginal mass. urethral diverticulum Educational objective: Endometriosis is the ectopic implantation of endometrial glands and stroma in the abdominopelvic cavity that can cause pain symptoms based on implant location. Patients with bladder implants typically have cyclic hematuria, dysuria, suprapubic tenderness, and negative urine culture. References: A rare cyclic recurrent hematuria case; bladder endometriosis. (http://www.ncbi.nlm.nih.gov/pubmed/26029655) Urinary tract endometriosis: review of 19 cases. (http://www.ncbi.nlm.nih.gov/pubmed/22346093)

A 24-Year-Old Woman Comes to the Office for Evaluation of Dysuria