How to manage a 90-year-old with recurrent hematuria unresponsive to antibiotics?

Management of Recurrent Hematuria in a 90-Year-Old Unresponsive to Antibiotics

In a 90-year-old patient with recurrent hematuria unresponsive to antibiotics, a urologic evaluation with cystoscopy is urgently recommended to rule out urologic malignancy, which has a high prevalence in this age group.

Initial Assessment

Risk Stratification

• Age >90 years is a significant risk factor for urologic malignancy
• Recurrent hematuria unresponsive to antibiotics suggests a non-infectious etiology
• Gross hematuria carries >10% risk of malignancy 1
• Elderly patients have higher prevalence of urologic malignancies, especially bladder cancer

Diagnostic Approach

Immediate Testing

• Urinalysis with microscopy to assess for:
  • Red blood cell morphology (dysmorphic vs. isomorphic)
  • Presence of red cell casts (suggesting glomerular origin)
  • Proteinuria (>1g/day suggests renal parenchymal disease) 2
• Urine culture to confirm lack of infection
• Serum creatinine to assess renal function

Imaging

• Computed Tomography Urography (CTU) is the preferred imaging study
  • Provides detailed anatomic depiction of the entire urinary tract
  • Excellent sensitivity and specificity for renal and urothelial lesions 2
  • Includes unenhanced, nephrographic, and excretory phases

Urologic Evaluation

Cystoscopy

• Mandatory in patients >40 years with hematuria, especially critical in a 90-year-old
• Direct visualization of bladder mucosa to detect lesions
• Standard white light cystoscopy is recommended (blue light cystoscopy not recommended for initial evaluation) 2

Urine Cytology

• Consider as an adjunct to cystoscopy
• Low sensitivity but high specificity for malignancy
• May detect high-grade lesions missed by cystoscopy 2

Management Algorithm

1. If urologic malignancy is detected:

   • Refer to urologic oncology for staging and treatment planning
   • Treatment options will depend on stage, grade, and patient's functional status

2. If urinary calculi are detected:

   • Consider urologic consultation for stone management
   • Options include observation, medical expulsive therapy, or procedural intervention

3. If no obvious cause is found after initial evaluation:

   • Consider less common causes:
     • Radiation cystitis (if history of pelvic radiation)
     • Drug-induced cystitis (particularly cyclophosphamide)
     • Arteriovenous malformations
     • Renal parenchymal disease (if dysmorphic RBCs or proteinuria present)

4. Follow-up recommendations:

   • If initial evaluation is negative, yearly urinalyses should be conducted 2
   • Consider repeat evaluation within 3-5 years if hematuria persists or recurs 2

Common Pitfalls and Caveats

• Avoid attributing hematuria solely to antibiotic use

  • While some antibiotics (particularly cefem group) can cause hematuria 3, this is rare and a diagnosis of exclusion

• Do not dismiss hematuria as "normal aging"

  • Hematuria in the elderly requires thorough evaluation regardless of age

• Avoid repeated antibiotic courses without definitive diagnosis

  • Continued antibiotic treatment without clear infection promotes resistance and delays diagnosis

• Do not treat asymptomatic bacteriuria

  • Common in elderly; treatment increases risk of symptomatic infection and bacterial resistance 4

• Consider functional status but do not withhold diagnostic evaluation

  • Even in a 90-year-old, diagnosis of malignancy may alter management and improve quality of life

Special Considerations in the Elderly

• Atypical presentation of UTI is common in older adults
• Elderly patients with hematuria have higher prevalence of significant pathology
• CT scans have higher sensitivity (92%) compared to ultrasound (50%) for detecting urologic pathology in patients with hematuria 5
• Logistic regression analysis shows age and number of RBCs/HPF are significant predictors of genitourinary cancer 5

Remember that recurrent hematuria in a 90-year-old warrants thorough evaluation regardless of antibiotic response, with particular attention to ruling out malignancy.