What is the appropriate workup for a 91-year-old male presenting to the Emergency Department (ED) with painful hematuria (bright red blood from the penis) of one week duration, with a history of colon cancer and currently taking warfarin (Coumadin, an anticoagulant)?

From the Guidelines

The appropriate workup for a 91-year-old male presenting to the Emergency Department (ED) with painful gross hematuria of one week duration, with a history of colon cancer and currently taking warfarin, is a thorough history, physical examination, urinalysis, and serologic testing, followed by cystoscopy and imaging evaluation 1.

Key Considerations

• Gross hematuria has a high association with malignancy of up to 30% to 40%, and therefore all patients with gross hematuria should have a full urologic workup 1.
• The patient's age (>35 years) and male gender are also risk factors for urinary malignancy 1.
• A history of colon cancer may increase the risk of genitourinary malignancy, and should be taken into consideration during the workup 1.
• The use of anticoagulant therapy, such as warfarin, does not alter the urologic evaluation of hematuria 1.

Workup Components

• Urinalysis to confirm the presence of hematuria and rule out infection or other abnormalities 1.
• Serologic testing to evaluate for renal function and other potential causes of hematuria 1.
• Cystoscopy to visualize the bladder and urethra for any malignant or benign lesions 1.
• Imaging evaluation, such as CT urography, to evaluate the upper urinary tract for any malignant or benign lesions 1.

From the Research

Initial Evaluation

The initial evaluation of a 91-year-old male presenting to the Emergency Department (ED) with painful hematuria of one week duration, with a history of colon cancer and currently taking warfarin, should include:

• A thorough medical history, including the patient's current medications and any potential interactions with warfarin 2
• A physical examination to identify any potential sources of bleeding
• Laboratory tests, such as a full blood count, urea and electrolyte levels, and coagulation studies to assess the patient's anticoagulation status 3

Imaging Studies

Imaging studies, such as:

• Intravenous urography (IVU) to evaluate the upper urinary tract 4
• Ultrasound to evaluate the kidneys and bladder
• Cystoscopy to evaluate the lower urinary tract and identify any potential sources of bleeding 4, 5

Considerations for Anticoagulation

Considerations for anticoagulation in this patient include:

• The risk of bleeding complications associated with warfarin therapy, particularly in patients with a history of malignancy 2
• The potential need to reverse anticoagulation in the event of significant bleeding
• The importance of monitoring the patient's anticoagulation status and adjusting their warfarin dose as needed 3

Management and Follow-up

Management and follow-up of this patient should include:

• Resuscitation and stabilization of the patient, as needed
• Prompt arrangement of follow-up with a urological team, ideally within the 2-week cancer referral target 6
• Discharge instructions, including advice to drink plenty of clear fluids and return for further medical attention if symptoms worsen or if the patient experiences clot retention, uncontrolled pain, or fever 6