What is the best management approach for a 33-year-old male patient presenting with hematuria, dysuria, and a suspected kidney stone?

From the Guidelines

The best management approach for a 33-year-old male with hematuria, dysuria, and suspected kidney stone should begin with a thorough history, physical examination, urinalysis, and serologic testing, as well as consideration of a full urologic workup, including cystoscopy, given the high association of gross hematuria with malignancy 1. The patient's symptoms of hematuria, dysuria, and suspected kidney stone require a comprehensive evaluation to determine the underlying cause.

• A non-contrast CT scan is the gold standard for diagnosing kidney stones and should be considered as part of the diagnostic workup 1.
• Pain control using NSAIDs like ibuprofen (600-800mg every 6-8 hours) or ketorolac (30mg IV or 10mg oral every 6 hours) can help manage symptoms, and alpha-blockers like tamsulosin 0.4mg daily can relax ureter muscles and facilitate stone passage.
• Hydration is crucial, and the patient should drink 2-3 liters of water daily to help pass the stone.
• The patient should strain urine to collect the stone for analysis, and indications for urological intervention include stones larger than 10mm, persistent severe pain, signs of infection (fever, elevated white blood cell count), renal impairment, or failure to pass the stone after 4-6 weeks.
• Given the patient's age and symptoms, it is essential to rule out other potential causes of hematuria, including malignancy, and a proper hematuria workup should be performed, including a thorough history, physical examination, urinalysis, and serologic testing 1.
• Antibiotics may be considered if a urinary tract infection is suspected, but urine cultures should be performed, preferably before antibiotic therapy, to confirm an infection 1.

From the Research

Evaluation and Management of Hematuria

• The patient's complaint of hematuria, dysuria, and a suspected kidney stone requires a thorough evaluation to determine the underlying cause 2.
• The primary care physician should answer three key questions: (1) Is it really hematuria? (2) Should this patient with hematuria be worked up, and if so, how? (3) Should this patient with hematuria be referred, and if so, to which specialty? 2.

Diagnostic Approach

• A urinalysis should be performed to evaluate the patient's hematuria and dysuria 3.
• Urine culture should be performed to guide appropriate antibiotic use, especially for recurrent or suspected complicated urinary tract infection 3.
• Imaging studies, such as a KUB x-ray, may be ordered to evaluate for kidney stones or other abnormalities 4.
• A non-contrast computed tomography (CT) scan of the kidneys, ureters, and bladder (KUB) may be considered to evaluate for nephrolithiasis, but efforts should be made to minimize radiation exposure by limiting the cranial extent of the scan to the T10 vertebral level 5.

Differential Diagnosis

• The patient's symptoms of hematuria and flank pain may be suggestive of nephrolithiasis, but other less common differentials, such as a Page kidney, should also be considered 6.
• A Page kidney is a diagnosis that describes compression of the renal parenchyma by a hematoma or mass causing secondary hypertension through the activation of the renin-angiotensin-aldosterone system 6.

Treatment Approach

• Antibiotics may be prescribed to treat a suspected urinary tract infection, but the choice of antibiotic should be guided by urine culture results 3.
• Further treatment will depend on the underlying cause of the patient's symptoms and may involve conservative measures, such as hypertension management, or more invasive measures, such as evacuation or nephrectomy 6.