A 35-year-old man presents with hematuria and left flank pain; abdominal X‑ray shows a radiopaque object in the urinary bladder. What is the most appropriate immediate step in management?

Immediate Hydration and Supportive Care

The most appropriate immediate step for this 35-year-old man with hematuria, left flank pain, and a radiopaque bladder stone is hydration (Option E), as this addresses the acute presentation while preparing for definitive urologic evaluation.

Rationale for Immediate Hydration

• Hydration is the cornerstone of initial management for suspected urolithiasis presenting with flank pain and hematuria, helping to facilitate stone passage and maintain renal perfusion while diagnostic evaluation proceeds 1

• The patient's presentation—hematuria with flank pain and a visible stone on imaging—strongly suggests urolithiasis with possible ureteral obstruction or irritation, making supportive care with hydration the appropriate first-line intervention 1

• Adequate hydration helps prevent acute kidney injury in the setting of potential obstruction and supports spontaneous stone passage for smaller stones 1

Why Other Options Are Inappropriate as Immediate Steps

Alpha-Blockers (Option A)

• Alpha-adrenergic blockers are indicated for ureteral stones to facilitate passage, but this patient has a bladder stone on imaging 1
• Medical expulsive therapy is not the immediate priority before confirming stone location and assessing for complications 1

Emergency ESWL (Option B)

• Extracorporeal shock wave lithotripsy is not an emergency procedure and is inappropriate for bladder stones 1
• ESWL is used for renal or upper ureteral stones, not bladder calculi 1
• The patient requires urgent urologic evaluation first, not immediate lithotripsy 1

N-Acetylcysteine and Ketoanalogues (Option C)

• These medications have no role in acute stone management 1
• N-acetylcysteine is used for contrast nephropathy prevention, not stone disease 1

Emergency Open Surgery (Option D)

• Open surgery is not indicated as an immediate step for a stable patient with a bladder stone 1
• Modern management of bladder stones typically involves cystoscopic removal, not open surgery 1

Critical Next Steps After Hydration

Urgent Urologic Evaluation Required

• All patients with gross hematuria require urgent urologic referral with cystoscopy and upper tract imaging, as gross hematuria carries a 30-40% malignancy risk even in younger patients 2, 3

• Cystoscopy is mandatory to directly visualize the bladder stone and exclude concurrent bladder pathology, as imaging alone cannot rule out malignancy 2, 3

• Multiphasic CT urography should be performed to evaluate the entire urinary tract, assess for additional stones, and exclude upper tract pathology 1, 2

Pain Management

• Provide adequate analgesia (NSAIDs or opioids as needed) while maintaining hydration 1

Laboratory Evaluation

• Confirm microscopic hematuria (≥3 RBCs/HPF) on urinalysis with microscopy 2
• Measure serum creatinine to assess renal function 2, 3
• Obtain urine culture if infection is suspected 2

Common Pitfalls to Avoid

• Do not delay urologic evaluation even though the patient is young (35 years); gross hematuria mandates complete evaluation regardless of age 2, 3

• Do not assume the stone explains all findings—the combination of hematuria and a visible stone does not exclude concurrent malignancy, and complete urologic assessment is required 1, 2

• Do not attribute hematuria solely to the stone without imaging confirmation and cystoscopic evaluation, as the American Urological Association advises against this practice 1

• Absence of infection markers does not exclude serious pathology—the negative leukocytes and nitrites appropriately rule out UTI, but the patient still requires urgent stone management and malignancy evaluation 1, 2