What is the appropriate evaluation and management for a patient with constant suprapubic and lower abdominal pain, hematuria, back pain, and pedal edema, with a history of kidney stones and irregular menses due to an implant?

Evaluation and Management of Suprapubic Pain with Hematuria and Back Pain

This patient requires urgent urologic referral and CT urography (non-contrast CT abdomen/pelvis) as the initial imaging study, given the combination of hematuria, flank/back pain, and history of kidney stones, which carries significant risk for urolithiasis, upper tract pathology, or malignancy. 1, 2

Immediate Diagnostic Workup

Laboratory Evaluation

• Obtain urinalysis with microscopic examination to quantify red blood cells per high-power field, assess for dysmorphic RBCs or red cell casts (suggesting glomerular source), and evaluate for white blood cells or bacteria 2
• Urine culture is mandatory to definitively exclude urinary tract infection, even with negative urinalysis dipstick, as lower bacterial counts may be clinically significant but not detected on dipstick 1, 2
• Serum creatinine to assess renal function and help differentiate glomerular from non-glomerular causes 2
• Pregnancy test given irregular menses with contraceptive implant 1

Imaging Strategy

• CT urography (or non-contrast CT abdomen/pelvis) is the gold standard imaging modality for evaluating hematuria with suspected urolithiasis, providing superior sensitivity for stones, renal masses, and complications 1
• Non-contrast CT has >95% sensitivity for detecting urinary stones and can identify alternative diagnoses such as renal masses, subcapsular hematomas, or hydronephrosis 1, 3
• Renal ultrasound is inadequate as the sole imaging modality in this clinical scenario, with only 75% sensitivity for urinary tract stones and 38% sensitivity for ureteral stones 1

Risk Stratification

High-Risk Features Present

This patient has multiple concerning features that mandate comprehensive evaluation:

• History of kidney stones increases recurrence risk and likelihood of current stone disease 4
• Hematuria (even if attributed to menses) requires full urologic workup to exclude malignancy or significant pathology 1, 2
• Constant pain for 1 month suggests ongoing pathology rather than self-limited process 1
• Back/flank pain with hematuria has 77% sensitivity for urolithiasis, though absence of hematuria does not exclude stones 3

Differential Diagnosis Considerations

• Urolithiasis remains most likely given history and presentation, though 23% of patients with stones may lack hematuria 3
• Loin pain-hematuria syndrome is possible but a diagnosis of exclusion requiring negative comprehensive workup 5, 6
• Upper tract urothelial malignancy must be excluded, particularly with persistent hematuria 1, 2
• Page kidney (subcapsular hematoma causing secondary hypertension) can present identically to nephrolithiasis 7

Urgent Urologic Referral Indications

Immediate urologic consultation is mandatory for the following reasons 1, 2:

• Any degree of hematuria in this clinical context requires cystoscopy to exclude bladder pathology 1
• Persistent symptoms for 1 month warrant intervention consideration 1
• History of kidney stones with new symptoms may indicate stone progression or complications 1

Cystoscopy Indications

• Cystoscopy should be performed to evaluate for bladder lesions, urethral pathology, or catheter-related trauma (if applicable) 1
• Flexible cystoscopy is equivalent or superior to rigid cystoscopy for most lesions and better tolerated 1

Management of Pedal Edema

The pedal edema requires separate evaluation as it may indicate:

• Renal dysfunction from bilateral obstruction or parenchymal disease (check serum creatinine and urinalysis for proteinuria) 2
• Venous insufficiency unrelated to urologic pathology 1
• Systemic process requiring additional workup if renal function is abnormal 1

Critical Pitfalls to Avoid

• Do not attribute hematuria solely to irregular menses without complete urologic evaluation, as this risks missing serious pathology 1, 2
• Do not delay imaging or urologic referral while pursuing conservative management, given the duration of symptoms 1, 2
• Do not assume pain is musculoskeletal without imaging to exclude urologic causes 7
• Do not treat empirically for urinary tract infection without documented positive urine culture, as asymptomatic bacteriuria should not be treated 1
• Absence of dysuria does not exclude significant urologic pathology and should not provide false reassurance 1

Follow-Up Protocol

If initial evaluation is negative:

• Repeat urinalysis at 6,12,24, and 36 months to monitor for persistent or recurrent hematuria 1, 2
• Monitor blood pressure at each visit, as new hypertension with hematuria suggests glomerular disease or Page kidney 2, 7
• Immediate re-evaluation required if gross hematuria develops, irritative voiding symptoms occur without infection, or abnormal cytology is found 1, 2