What is the cause of hematuria in a 68-year-old female with a pelvic calcification of uncertain significance on X-ray KUB?

Evaluation of Hematuria in a 68-Year-Old Female with Pelvic Calcification on X-ray KUB

For a 68-year-old female with hematuria and a pelvic calcification of uncertain significance on X-ray KUB, CT urography is strongly recommended as the next diagnostic step to determine the cause of hematuria, as this has the highest sensitivity (92%) and specificity (93%) for detecting urinary tract pathology. 1

Interpretation of Current X-ray KUB Findings

The current X-ray KUB shows:

• Nonobstructive bowel gas pattern
• Copious stool throughout the colon
• Residual air in the transverse colon
• No visible urolithiasis
• Mid-pelvic calcification of uncertain significance (possibly uterine fibroid or bladder stone/calcification)

Risk Assessment for Urologic Malignancy

This patient has several risk factors that warrant thorough evaluation:

• Age >60 years (patient is 68)
• Female gender
• Presence of hematuria
• Unexplained pelvic calcification

Diagnostic Algorithm

1. Initial Laboratory Evaluation

   • Complete urinalysis to confirm hematuria and assess for pyuria, bacteriuria, crystals, and casts
   • Complete metabolic panel including BUN, creatinine, and electrolytes
   • Urine culture to rule out infection
   • Urine cytology to evaluate for malignant cells

2. Imaging Studies

   • CT Urography is the preferred imaging modality for this patient given:
     • High sensitivity (92%) and specificity (93%) for urinary tract pathology 1
     • Ability to characterize the uncertain pelvic calcification
     • Comprehensive evaluation of the entire urinary tract
     • Superior to X-ray KUB which has limited sensitivity (53-62%) for urinary calculi 2

3. Specialist Referral

   • Urology referral is indicated due to:
     • Presence of gross hematuria
     • Age >60 years
     • Uncertain pelvic calcification that could represent bladder pathology
   • Consider nephrology referral if evidence of renal dysfunction (eGFR <60 ml/min/1.73m²) is found

Differential Diagnosis of Hematuria with Pelvic Calcification

1. Urinary Tract Pathology

   • Bladder stone or calcification
   • Bladder malignancy with calcification
   • Urolithiasis (though not visible on current X-ray)
   • Urothelial carcinoma

2. Gynecologic Causes

   • Calcified uterine fibroids
   • Ovarian calcifications
   • Gynecologic malignancy with calcification

3. Other Considerations

   • Vascular calcifications
   • Phleboliths
   • Calcified lymph nodes

Important Considerations

• X-ray KUB alone is insufficient for evaluating hematuria, particularly in high-risk patients. The American College of Radiology notes that "radiography (KUB) is generally not appropriate in the initial evaluation of isolated nonpainful, nontraumatic hematuria" 2

• Never attribute hematuria to anticoagulant therapy without proper evaluation - these patients still require complete workup 1

• The risk of malignancy with gross hematuria is greater than 10%, necessitating prompt and thorough evaluation 3

• Cystoscopy should be considered in this patient given her age and the presence of hematuria, regardless of imaging findings, as recommended by the American Urological Association 1

• Do not assume the pelvic calcification is benign without definitive characterization through advanced imaging