From the Guidelines
The patient should be referred for further urologic evaluation, including cystoscopy, due to the presence of 3+ blood in the urine and flank pain, as recommended by the American College of Physicians 1. The patient's symptoms and laboratory results suggest a possible underlying urologic condition that requires further investigation. The imaging studies, including the X-ray KUB and ultrasound of the kidneys, have ruled out kidney stones and structural abnormalities, but the presence of blood in the urine and flank pain necessitate a more thorough evaluation. The patient's current treatment with Flomax (tamsulosin) may help with urinary symptoms, but it is not addressing the underlying cause of the hematuria. According to the American College of Physicians, adults with microscopically confirmed hematuria in the absence of a demonstrable benign cause should be considered for urology referral for cystoscopy and imaging 1. Additionally, the American Urological Association recommends that cystoscopic evaluation of the bladder is necessary to exclude the presence of bladder cancer in patients with hematuria, especially those over 40 years of age 1. Therefore, a referral to a urologist for further evaluation, including cystoscopy, is warranted to rule out any underlying malignancy or other significant urologic conditions. The patient should also be advised to maintain adequate hydration and follow up in 1-2 weeks to reassess symptoms and repeat urinalysis to confirm resolution of hematuria. It is also important to note that the patient's treatment with Rocephin (ceftriaxone) may have addressed a possible infectious cause, but further evaluation is still necessary to determine the underlying cause of the hematuria. Key points to consider in the patient's management include:
- Referral to a urologist for further evaluation, including cystoscopy
- Continued treatment with Flomax (tamsulosin) for urinary symptoms
- Maintenance of adequate hydration
- Follow-up in 1-2 weeks to reassess symptoms and repeat urinalysis
- Consideration of additional diagnostic tests, such as urine cytology, if hematuria persists after treatment.
From the FDA Drug Label
Patients with Renal or Hepatic Impairment Ceftriaxone is excreted via both biliary and renal excretion Ensure adequate hydration in patients receiving ceftriaxone Discontinue ceftriaxone in patients who develop signs and symptoms suggestive of urolithiasis, oliguria or renal failure and/or the sonographic findings described above.
The patient has been treated with ceftriaxone for three days. Given that the patient has blood in the urine and flank pain, but no urolithiasis was detected, the next step would be to:
- Monitor the patient's renal function and urine output
- Ensure adequate hydration to prevent potential urolithiasis or renal failure
- Re-evaluate the patient's symptoms and consider alternative causes of hematuria and flank pain
- Consider discontinuing ceftriaxone if the patient develops any signs of urolithiasis or renal failure 2
From the Research
Patient Evaluation
The patient presents with flank pain and hematuria, which are common symptoms of nephrolithiasis. However, the X-ray KUB and US of the kidneys did not show any evidence of urolithiasis.
- The X-ray KUB showed surgical clips in the right upper quadrant and large amounts of stool and gas within the colon, but no calculi were seen overlying the renal shadows or within the typical course of the ureters.
- The US of the kidneys showed normal size, shape, and echogenicity, with no evidence of hydronephrosis, mass, or nephrolithiasis.
Differential Diagnosis
Given the absence of urolithiasis, it is essential to consider other potential causes of the patient's symptoms.
- A study published in 3 highlights the importance of considering alternative diagnoses, such as Page kidney, which can cause secondary hypertension.
- Another study published in 4 suggests that hematuria testing may not be sufficient to diagnose ureterolithiasis and may be misleading, as other serious conditions can also cause hematuria.
Next Steps
Based on the patient's presentation and the lack of evidence for urolithiasis, the next steps could include:
- Further evaluation to rule out other causes of flank pain and hematuria, such as CT scans or other imaging modalities, as suggested in 5, 6, and 7.
- Consideration of alternative diagnoses, such as Page kidney or other conditions that can cause secondary hypertension, as discussed in 3.
- Continued monitoring of the patient's symptoms and adjustment of treatment as needed, taking into account the patient's current medication regimen, including Flomax 0.8 mg QD.