What is the cause of left flank pain and hematuria in a 43-year-old male with a family history of genitourinary cancers and no evidence of urolithiasis on X-ray KUB?

From the Guidelines

I strongly recommend that this 43-year-old male patient with persistent left flank pain and significant hematuria undergo a CT urogram or renal ultrasound to better visualize the urinary tract, along with urine cytology and comprehensive urinalysis with culture, given the limited sensitivity of the KUB X-ray in detecting all potential causes of his symptoms 1. The patient's symptoms of left flank pain and 3+ blood in the urine, combined with a family history of urological cancers, necessitate a more comprehensive investigation to rule out malignancies or other serious conditions. The KUB X-ray findings, which showed no calculi overlying the renal shadows or within the typical course of the ureters, do not exclude other potential causes of hematuria, such as tumors, infection, or glomerular disease 1. Given the patient's age, gender, and family history, the risk of urinary malignancy is a concern, and a thorough evaluation is warranted 1. While waiting for these evaluations, pain management with acetaminophen 500-1000mg every 6 hours or NSAIDs like ibuprofen 400-600mg every 6-8 hours (if not contraindicated) is appropriate, and the patient should increase fluid intake to 2-3 liters daily to help clear any microscopic debris. Referral to a urologist is also recommended for specialized assessment, given the patient's significant hematuria and family history of urological cancers 1. Additionally, a CT abdomen and pelvis with IV contrast may be useful in this setting, as it can provide a more comprehensive evaluation of the urinary tract and help identify potential causes of the patient's symptoms 1. However, the choice of imaging modality should be guided by the patient's clinical presentation and the suspected underlying cause of his symptoms. In this case, the combination of significant hematuria, flank pain, and family history of urological malignancies necessitates a thorough and comprehensive evaluation to rule out serious conditions. Key points to consider in the patient's evaluation include:

• Significant hematuria (3+) and flank pain
• Family history of urological cancers
• Limited sensitivity of KUB X-ray in detecting all potential causes of hematuria
• Need for comprehensive evaluation, including CT urogram or renal ultrasound, urine cytology, and comprehensive urinalysis with culture
• Referral to a urologist for specialized assessment
• Pain management and increased fluid intake while awaiting evaluation.

From the Research

Patient Presentation and History

• The patient is a 43-year-old male presenting with left flank pain and 3+ blood in the urine.
• The pain starts in the middle of the back and radiates to the left side, with the patient reporting a deep sensation.
• The patient has a family history of bladder and kidney cancer, with one uncle dying of bladder cancer and another having kidney cancer.

Diagnostic Imaging

• An X-ray KUB was performed, which showed:
  • Surgical clips in the right upper quadrant.
  • Large amounts of stool and gas within the colon overlying the kidneys.
  • No calculi seen overlying the renal shadows or within the typical course of the ureters.
  • Bony structures appear intact and well mineralized.
• The impression from the X-ray KUB is that there is no discernible urolithiasis.

Relevant Studies

• A study from 2011 2 suggests that computed tomography-urography (CTU) is indicated for patients with macroscopic hematuria, as it can help detect upper urinary tract lesions.
• Another study from 2020 3 compares the sensitivity and specificity of contrast-enhanced ultrasound (CEUS), computed tomography (CT), and magnetic resonance imaging (MRI) in evaluating unclear renal lesions, finding that CEUS has a comparable sensitivity and specificity to CT and MRI.
• A study from 2011 4 discusses the role of CT and MRI in imaging the urinary tract, highlighting their complementary advantages and disadvantages.
• A 2023 study 5 provides an overview of computed tomography urography (CTU), including its protocols, strengths, and limits, as well as the potential of new reconstruction algorithms and artificial intelligence applications.
• A 2016 study 6 reviews the use and clinical applications of computed tomography (CT) in evaluating human body composition, including its ability to distinguish between different body compartments and estimate their area and volume.

Potential Next Steps

• Consider ordering a CTU or other imaging modalities to further evaluate the patient's left flank pain and hematuria, given the family history of bladder and kidney cancer and the lack of discernible urolithiasis on the X-ray KUB.
• The choice of imaging modality may depend on the patient's specific clinical question and the advantages and disadvantages of each technique, as discussed in the relevant studies 2, 3, 4, 5, 6.