What is the next step in managing a patient with symptoms of hematuria and foul-smelling urine, an abnormal CT scan, and a scheduled cystoscopy in the urology department?

Next Steps for Patient with Hematuria, Foul-Smelling Urine, and Abnormal CT Scan

Proceed directly with the scheduled cystoscopy and ensure upper tract imaging (CT urography) has been completed—do not delay evaluation for any reason, as this patient requires urgent and complete urologic assessment given the combination of symptoms and abnormal imaging. 1

Immediate Pre-Cystoscopy Verification

Confirm Complete Imaging Workup

• Verify that multiphasic CT urography has been performed, not just a standard CT scan, as CT urography includes unenhanced, nephrographic phase, and excretory phase images necessary to comprehensively evaluate kidneys, collecting systems, ureters, and bladder for transitional cell carcinoma, renal cell carcinoma, and urolithiasis 1, 2
• If only a standard CT was obtained, CT urography must be completed before or concurrent with cystoscopy to avoid missing upper tract urothelial malignancies 1

Laboratory Confirmation

• Obtain urine culture if not already done, as foul-smelling urine suggests possible infection that should be documented before cystoscopy 1
• Confirm microscopic hematuria with ≥3 RBCs per high-power field on urinalysis with microscopy if only dipstick testing was performed 1, 3
• Measure serum creatinine to assess renal function before any contrast-enhanced procedures 1, 3

Cystoscopy Procedure Planning

Technical Approach

• Flexible cystoscopy is preferred over rigid cystoscopy for initial diagnostic evaluation, as it causes less pain, has fewer post-procedure symptoms, and demonstrates equivalent or superior diagnostic accuracy 1, 3, 4
• Complete visualization of bladder mucosa, urethra, and ureteral orifices is mandatory to exclude bladder transitional cell carcinoma, which is the most frequently diagnosed malignancy in hematuria cases 1, 3, 4

Concurrent Diagnostic Procedures

• Voided urine cytology should be obtained if the patient has high-risk features (age, smoking history, occupational exposures), though it should not delay cystoscopy 1, 3
• Do NOT obtain FDA-approved urine markers (NMP22, BTA stat, ImmunoCyt, UroVysion) as they are specifically not recommended for initial hematuria evaluation and miss 18-43% of bladder cancers while giving false-positives in 12-26% 1

Critical Decision Points During Cystoscopy

If Bladder Lesion Identified

• Perform bimanual examination under anesthesia to assess for muscle invasion 1
• Schedule transurethral resection of bladder tumor (TURBT) with adequate muscle sampling to determine depth of invasion—small fragments with few muscle fibers are inadequate for staging 1
• Multiple random biopsies should be performed if carcinoma in situ is suspected, and consider TUR biopsy of the prostate 1

If Cystoscopy is Normal

• Review CT urography results carefully for upper tract abnormalities, as cystoscopy alone misses upper tract malignancies 1, 3, 5
• Do not assume negative cystoscopy excludes malignancy—sensitivity of cystoscopy ranges from 87-100%, meaning up to 13% of cancers may be missed on initial examination 1

Post-Cystoscopy Management Algorithm

If Complete Workup is Negative

• Establish surveillance protocol with repeat urinalysis at 6,12,24, and 36 months with blood pressure monitoring at each visit 1, 3, 4
• Immediate re-evaluation is warranted if gross hematuria develops, significant increase in microscopic hematuria occurs, new urologic symptoms appear, or development of hypertension/proteinuria 3, 4, 5

If Infection is Confirmed

• Treat urinary tract infection appropriately and repeat urinalysis 6 weeks after treatment 1
• If hematuria persists after infection treatment, proceed with full urologic evaluation—infection does not explain hematuria and should not defer comprehensive assessment 1, 3

Special Considerations and Common Pitfalls

Do Not Delay for These Reasons

• Anticoagulation or antiplatelet therapy is not a reason to defer evaluation—these medications may unmask underlying pathology but do not cause hematuria 1, 3, 4
• Self-limited hematuria still requires complete evaluation, as 30-40% of gross hematuria cases are associated with malignancy 1, 4
• Foul-smelling urine suggesting infection does not exclude concurrent malignancy—both evaluations must be completed 1

Risk Stratification Context

• Any abnormal CT scan finding in a patient with hematuria elevates concern for malignancy and mandates complete urologic evaluation regardless of other risk factors 1
• Gross hematuria carries 30-40% malignancy risk; microscopic hematuria carries 2.6-4% risk overall but higher in patients with abnormal imaging 1, 4

Glomerular vs. Urologic Source

• Examine urinary sediment for dysmorphic RBCs (>80% suggests glomerular) and red cell casts (pathognomonic for glomerular disease) 1, 3, 4
• Check for significant proteinuria using spot urine protein-to-creatinine ratio—values >0.5 g/g strongly suggest renal parenchymal disease 3, 4
• Even if glomerular features are present, complete urologic evaluation must still be performed, as malignancy can coexist with medical renal disease 3, 4