What is the best course of action for an 80-year-old patient with flank pain and hematuria (blood in urine), with a urinalysis showing no leukocytes (white blood cells) and no nitrates, and a large amount of blood in the urine?

Urgent Urologic Referral for Gross Hematuria in Elderly Patient with Flank Pain

Your 80-year-old patient with flank pain and gross hematuria requires urgent urologic referral for cystoscopy and CT urography to rule out urinary tract malignancy, which has a high probability in this age group.

Initial Assessment

• Gross hematuria (visible blood in urine) carries a significantly higher risk of malignancy (30-40%) compared to microscopic hematuria (2.6-4%), especially in elderly patients 1
• The combination of flank pain and hematuria in an elderly patient raises concern for several serious conditions including:
  • Urinary tract malignancy (bladder or upper tract) 2
  • Urolithiasis (kidney stones) 3
  • Renal infarction 4
  • Less commonly, Page kidney or other vascular pathologies 5

Diagnostic Approach

Laboratory Evaluation

• The urinalysis already shows large blood (200) with negative leukocytes and nitrites, suggesting a non-infectious etiology 2
• Additional testing should include:
  • Serum creatinine to assess renal function 1
  • Complete blood count to evaluate for anemia or leukocytosis 1
  • Urine cytology is recommended in elderly patients due to high risk of transitional cell carcinoma 1

Imaging Studies

• CT urography (CT abdomen/pelvis with IV contrast) is the preferred initial imaging modality for comprehensive evaluation of the urinary tract in an 80-year-old with hematuria 2, 1
  • Provides detailed visualization of the kidneys, ureters, and bladder
  • Can identify stones, masses, vascular abnormalities, and other pathologies
• If CT is contraindicated (e.g., severe contrast allergy or renal insufficiency):
  • MR urography is an acceptable alternative 1
  • Renal ultrasound with retrograde pyelography can be considered if CT and MR are not feasible 1

Specialist Referral

• Urgent urologic referral is mandatory for all patients with gross hematuria, even if self-limited 2
• The urologist will likely perform:
  • Cystoscopy (complete visualization of the bladder mucosa, urethra, and ureteral orifices) to exclude bladder cancer 2
  • Additional imaging if not already performed 2

Important Considerations

• Do not delay evaluation even if hematuria resolves spontaneously 2
• The absence of infection markers (negative leukocytes and nitrites) increases concern for malignancy or other serious pathology 2
• Advanced age (80 years) significantly increases the risk of urinary tract malignancy 1
• Flank pain with hematuria is often attributed to kidney stones, but this can lead to missed diagnoses of more serious conditions 5, 3

Common Pitfalls to Avoid

• Do not assume hematuria is due to antiplatelet or anticoagulant medications if the patient is taking them - these medications do not cause hematuria but may unmask underlying pathology 2
• Do not rely solely on urinalysis findings - up to 11% of patients with ureterolithiasis may have no hematuria, and conversely, hematuria can occur in many conditions unrelated to stones 3
• Do not delay urologic referral while waiting for other test results in a patient with gross hematuria 2
• Do not attribute symptoms to urinary tract infection without positive leukocytes or nitrites 2

Remember that in an 80-year-old patient with gross hematuria, the risk of malignancy is substantial, and prompt evaluation is essential to ensure early diagnosis and treatment of potentially life-threatening conditions.