The patient’s clinical presentation is suspicious for a urinary-tract malignancy. A full urologic evaluation of the entire urinary tract is required with cystoscopy and intravenous pyelography (IVP).
Hematuria can have multiple etiologies, but risk factors for malignancy includes advanced age, smoking history, occupational exposure to chemicals or dyes (benzenes, aromatic amines), chronic cystitis, pelvic irradiation, cyclophosphamide exposure, chronic indwelling foreign body, and history of analgesic abuse. In this vignette, the patient has two risk factors (advanced age, smoking). Bladder cancer is the most common malignancy of the urinary tract, and commonly presents with hematuria (with or without pain), dysuria, frequency, urgency, and constitutional symptoms.
Choyke discusses the recommended imaging studies for the presentation of hematuria. While IVP has traditionally been a standard modality of upper tract visualization, ultrasonography and CT have recently been investigated as viable alternatives and are gaining traction. CT urography is a new technique produces images similar to IVP while also giving traditional CT images as well.
Loo et al. conducted a prospective cohort study of patients evaluated for asymptomatic microscopic hematuria and report the development of a Hematuria Risk Index to identify patients at high risk, which include those risk factors previously mentioned. They suggest that more extensive evaluations for malignancy only be conducted in patients who have been risk stratified and identified as high risk individuals.
Illustration A is an IVP study. After injection of contrast, a radiograph is taken to show excretion into the lower ureters and bladder. Note the mass-like filling defect (arrows), suggestive of a large bladder carcinoma.
Answer 1: A kidney, ureter, bladder plain film series is used to identify nephrolithiasis.
Answer 3: MRI of the abdomen and pelvis is not the first imaging study ordered in the workup of urinary tract malignancy.
Answer 4: Urine cytology can be helpful as an adjunct to cystoscopy.
Answer 5: Antibiotics are not an appropriate first choice in management without confirmation of infection.
Choyke PL. Radiologic evaluation of hematuria: guidelines from the American College of Radiology's appropriateness criteria. Am Fam Physician. 2008 Aug 1;78(3):347-52.
PMID:18711950 (Link to Abstract)
Loo RK, Lieberman SF, Slezak JM, Landa HM, Mariani AJ, Nicolaisen G, Aspera AM, Jacobsen SJ. Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria. Mayo Clin Proc. 2013 Feb;88(2):129-38.
PMID:23312369 (Link to Abstract)
USMLE Step 2 CK Qbook 4th ed. Daugherty, Stephen R. New York: Kaplan Publishing, 2008.