What is the diagnosis for an 82-year-old patient on Coumadin (warfarin) presenting with hematuria, urinary urgency, dysuria, and frequency with frank blood?

From the Guidelines

This 82-year-old patient on Coumadin with hematuria, urgency, dysuria, frequency, and frank blood should be evaluated urgently with a focus on ruling out serious conditions like bladder cancer, which is more common in elderly patients, as suggested by the most recent guideline updates 1. The patient's presentation with gross hematuria, which has a high association with malignancy, necessitates a thorough evaluation, including cystoscopy, upper tract imaging, and urinary cytology, as recommended by the American Urological Association (AUA) and supported by recent studies 1. First, check the patient's INR to determine if anticoagulation is supratherapeutic, as excessive anticoagulation can cause or worsen bleeding, and temporarily holding Coumadin may be necessary depending on INR results and the patient's indication for anticoagulation. A urinalysis with culture should be obtained to check for urinary tract infection (UTI), which could explain the dysuria, frequency, and urgency, and if a UTI is confirmed, appropriate antibiotics such as nitrofurantoin 100mg twice daily for 7 days (if renal function permits) or trimethoprim-sulfamethoxazole 160/800mg twice daily for 3-5 days should be prescribed, avoiding fluoroquinolones in the elderly if possible, as suggested by previous guidelines 1. Key considerations in the evaluation and management of this patient include:

• Urgent urological evaluation to rule out serious conditions like bladder cancer
• Cystoscopy, upper tract imaging, and urinary cytology as part of the evaluation
• Management of anticoagulation therapy, including potential temporary cessation of Coumadin
• Treatment of any underlying UTI or other conditions contributing to the patient's symptoms
• Close follow-up to ensure resolution of symptoms and to adjust anticoagulation therapy as needed, with consideration of the most recent guideline updates 1.

From the Research

Patient Presentation

The patient is an 82-year-old on Coumadin presenting with hematuria, urgency, dysuria, and frequency with frank blood.

Evaluation of Hematuria

• Evaluation of hematuria should always include dipstick analysis and microscopic examination of urine 2
• The patient's age and clinical presentation suggest the need for a thorough evaluation to determine the cause of hematuria
• Urinalysis results, including the presence of red blood cells, protein, and other abnormalities, can help guide further diagnostic testing and management

Differential Diagnosis

• The most common cause of acute dysuria is infection, especially cystitis 3
• Other potential causes of dysuria and hematuria include urethritis, sexually transmitted infections, vaginitis, and non-infectious inflammatory and non-inflammatory conditions
• The patient's symptoms and age suggest the need to consider a range of potential causes, including urinary tract infections, kidney stones, and malignancy

Diagnostic Testing

• CT urography (CTU) may be considered in patients with hematuria, but its yield for upper urinary tract malignancy is low 4
• Urinalysis, including dipstick analysis and microscopic examination, is an essential diagnostic tool in evaluating patients with hematuria and dysuria 2, 5
• Further diagnostic testing, such as cystoscopy and imaging studies, may be necessary to determine the cause of the patient's symptoms and to guide management

Management

• The patient's anticoagulation therapy with Coumadin should be considered when evaluating and managing their hematuria and dysuria
• The patient's symptoms and diagnostic test results should guide further management, which may include antibiotic therapy, pain management, and referral to a specialist if necessary 3