What is the appropriate management for a patient presenting with hematuria, lower back pain, headaches, and vital sign instability, including hypothermia and bradycardia?

Urgent Evaluation and Management of Hematuria with Systemic Symptoms

This patient requires immediate hospital evaluation for potential acute pyelonephritis, renal infarction, or other serious genitourinary pathology given the constellation of hematuria, flank pain, daily headaches, and vital sign instability. 1, 2

Immediate Triage and Assessment

Rapid transfer to a hospital with emergency department capabilities is essential, as vital sign instability (hypothermia to 96.6°F, relative bradycardia at 68 bpm when normally 80s-90s) combined with hematuria and flank pain suggests potential hemodynamic compromise or systemic illness. 3

Critical Initial Monitoring

• Continuous vital sign monitoring including pulse oximetry, blood pressure, heart rate, respiratory rate, and temperature 3
• Urine output monitoring (though routine catheterization is not recommended unless clinically indicated) 3
• ECG monitoring to assess for arrhythmias that could explain bradycardia 3

Diagnostic Workup Priority

Immediate Laboratory Testing

• Urinalysis with microscopy to confirm true hematuria (≥3 RBCs/HPF) and assess for dysmorphic RBCs, red cell casts, or proteinuria 1
• Urine culture to rule out complicated urinary tract infection or pyelonephritis 1, 2
• Serum creatinine and electrolytes to assess renal function 1
• Complete blood count to evaluate for anemia or infection 2
• Inflammatory markers (C-reactive protein, procalcitonin) if sepsis is suspected 3

Urgent Imaging

CT scan without contrast (CT urography if renal function permits) is indicated to evaluate for: 1, 2

• Renal stones (though the vital sign instability and daily headaches suggest more than simple nephrolithiasis) 4
• Renal infarction or subcapsular hematoma (Page kidney), which can present with flank pain, hematuria, and new-onset hypertension 4
• Pyelonephritis with complications such as abscess formation 2
• Obstructive uropathy 2

Risk Stratification for Malignancy

While acute management takes priority, this patient's hematuria requires risk-based evaluation: 1

• Age, smoking history, and occupational exposures determine risk category 1
• High-risk features include age ≥60 years, >30 pack-years smoking, history of gross hematuria, or >25 RBC/HPF 1
• Intermediate-risk includes women age 50-59 or men 40-59,10-30 pack-years smoking, or 11-25 RBC/HPF 1

Differential Diagnosis Considerations

Acute Pyelonephritis

If fever, flank pain, and pyuria are present, acute pyelonephritis is likely and requires: 2

• Immediate empiric antibiotic therapy (fluoroquinolones or trimethoprim-sulfamethoxazole if local resistance <10%) 2
• One dose of long-acting parenteral antibiotic if oral resistance likely exceeds 10% 2
• Hospital admission if unable to tolerate oral therapy, septic, or pregnant 2

Glomerular vs. Non-Glomerular Source

Examine urinary sediment for: 1

• Dysmorphic RBCs (>80% suggests glomerular source) 1
• Red cell casts (pathognomonic for glomerular disease) 1
• Significant proteinuria (>500 mg/24 hours suggests glomerular pathology) 1
• If glomerular source identified, nephrology referral is indicated 1

Loin Pain-Hematuria Syndrome

While this rare condition (prevalence ~0.012%) presents with severe flank pain and hematuria, it typically occurs in young women without vital sign instability and is a diagnosis of exclusion after ruling out serious pathology 5, 6

Management Algorithm

If Infection Suspected

1. Start empiric antibiotics immediately while awaiting culture results 2
2. Reassess at 48-72 hours; if no improvement, obtain repeat cultures and imaging 2
3. If obstruction identified, urgent urologic consultation for decompression 2

If Vital Signs Normalize and Infection Ruled Out

1. Complete urologic evaluation with cystoscopy and upper tract imaging based on risk stratification 1
2. Repeat urinalysis 6 weeks after any UTI treatment to confirm resolution 1
3. If hematuria persists after negative initial workup, repeat UA at 6,12,24, and 36 months with blood pressure monitoring 1

Critical Pitfalls to Avoid

• Do not attribute hematuria solely to anticoagulation or antiplatelet therapy without complete evaluation 1
• Do not delay evaluation assuming simple nephrolithiasis when vital signs are unstable 4
• Do not miss Page kidney (subcapsular hematoma causing secondary hypertension) in patients with flank pain, hematuria, and new hypertension 4
• Do not discharge without confirming resolution of hematuria after UTI treatment, as 3% of patients with microscopic hematuria harbor genitourinary malignancy 1

Headache Consideration

The daily headaches since symptom onset warrant evaluation for secondary hypertension (particularly if Page kidney or renal artery stenosis identified) or other systemic processes, though this should not delay evaluation of the potentially life-threatening genitourinary pathology 4