From the Guidelines
The patient requires a comprehensive urological evaluation, including cystoscopy and possibly cytology, to investigate the source of bleeding and exclude malignancy, given the significant hematuria and family history of urological cancers, despite normal imaging results. The patient, a 43-year-old male prisoner with left flank pain and significant hematuria (3+ blood in urine), has a concerning family history of urological cancers, which increases the risk of urinary tract malignancy 1. According to the American Urological Association, gross hematuria has a high association with malignancy, and all patients with gross hematuria should have a full urologic workup 1.
The recent guideline updates on microhematuria emphasize the importance of cystoscopy in evaluating hematuria, particularly in patients with risk factors for malignancy, such as age, smoking, and family history 1. The diagnostic accuracy of cystoscopy for detecting bladder cancer in adults presenting with hematuria has been systematically reviewed, highlighting its importance in diagnosing urothelial bladder cancer 1.
Given the patient's symptoms and family history, the referral for urology consultation is essential. The physician has appropriately prescribed pain management with tramadol and antibiotic therapy with Bactrim DS, following an initial course of Rocephin. However, further investigation, including microscopic evaluation of urine, cystoscopy, and possibly cytology, is necessary to determine the cause of hematuria and rule out malignancy. The combination of antibiotics suggests treatment for a possible urinary tract infection, though culture results were not mentioned in the case presentation.
Key considerations in the patient's management include:
- Comprehensive urological evaluation, including cystoscopy and possibly cytology
- Microscopic evaluation of urine to investigate the source of bleeding
- Family history of urological cancers, which increases the risk of urinary tract malignancy
- Recent guideline updates on microhematuria, emphasizing the importance of cystoscopy in evaluating hematuria
- Diagnostic accuracy of cystoscopy for detecting bladder cancer in adults presenting with hematuria 1.
From the Research
Patient Presentation and Treatment
- The patient presents with left-side flank pain and 3+ blood in the urine, with a family history of bladder and kidney cancer.
- The patient was treated with Rocephin 1000 mg daily for three days and was prescribed tramadol 50 mg 2 tabs BID for pain and Bactrim DS BID for 14 days.
- The patient was referred for a urology consult.
Diagnostic Findings
- X-ray KUB findings: no calculi seen overlying the renal shadows or within the typical course of the ureters, and no discernible urolithiasis.
- US of the kidneys: normal renal ultrasound evaluation, with no evidence of hydronephrosis, mass, or nephrolithiasis.
Treatment Rationale
- The use of trimethoprim-sulfamethoxazole (Bactrim DS) for urinary tract infections is supported by studies such as 2, which notes its effectiveness against usual aerobic gram-negative bacteria.
- However, studies such as 3 and 4 suggest that trimethoprim-sulfamethoxazole may be associated with an increased risk of acute kidney injury and hyperkalaemia, particularly in older patients or those with certain underlying conditions.
- The use of tramadol for pain management is supported by studies such as 5, which notes its effectiveness and relatively low risk of adverse effects.
Considerations for Future Management
- The patient's family history of bladder and kidney cancer may warrant further investigation and monitoring.
- The potential risks and benefits of continued trimethoprim-sulfamethoxazole use should be carefully considered, particularly in light of the patient's age and underlying health status.
- Alternative treatment options, such as those discussed in 6, may be worth considering in order to minimize the risk of antibiotic resistance and other adverse effects.