What is the likely diagnosis for a 43-year-old male with left flank pain, hematuria, and a family history of genitourinary cancers, given normal renal ultrasound and no urolithiasis?

From the Guidelines

The patient requires a thorough urological evaluation, including cystoscopy, to rule out underlying conditions such as malignancy or other urological disorders, given the unexplained hematuria and family history of urological cancers, despite normal imaging results 1. The patient, a 43-year-old male prisoner with left flank pain and hematuria (3+ blood in urine), has a concerning family history of urological cancers, with one uncle dying of bladder cancer and another having kidney cancer.

• The normal imaging results from both KUB X-ray and renal ultrasound, which show no evidence of kidney stones, masses, or structural abnormalities, do not rule out the possibility of urological malignancies or other disorders.
• The American College of Radiology (ACR) Appropriateness Criteria for hematuria recommend a thorough history and physical examination, urinalysis, and serologic testing prior to any initial imaging 1.
• The American Urological Association (AUA) best practice policy recommendations for asymptomatic microscopic hematuria suggest that cystoscopic evaluation of the bladder is necessary to exclude the presence of bladder cancer, especially in patients over 40 years old or with risk factors for bladder cancer 1.
• Given the patient's age and family history, cystoscopy is a crucial component of the initial evaluation, and the referral for urology consultation is essential to pursue specialized evaluation and rule out serious underlying conditions.
• The combination of antibiotics, including Bactrim DS twice daily for 14 days, following an initial three-day course of Rocephin 1000mg daily, suggests treatment for a possible urinary tract infection, though the persistent hematuria despite normal imaging requires thorough urological assessment.
• The patient's pain management with tramadol 50mg two tablets twice daily is appropriate, but the underlying cause of the hematuria and flank pain must be investigated further to ensure optimal treatment and outcomes.

From the Research

Patient Presentation and Diagnosis

• The patient presents with left-side flank pain that starts in the middle of the back and radiates to the left side, with a reported depth of pain
• The patient has a family history of bladder and kidney cancer, with one uncle dying of bladder cancer and another having kidney cancer
• Diagnostic tests include an X-ray KUB, which showed no discernible urolithiasis, and a renal ultrasound, which showed normal kidney size, shape, and echogenicity with no evidence of hydronephrosis, mass, or nephrolithiasis

Treatment and Management

• The patient was initially treated with Rocephin 1000 mg daily for three days
• The patient is being prescribed tramadol 50 mg 2 tabs BID for pain management, as supported by studies such as 2, which notes that tramadol is effective for mild to moderate pain intensity
• The patient is also being prescribed Bactrim DS BID for 14 days, and a urology consult has been referred
• However, it is essential to consider the potential risks associated with tramadol use, such as the increased risk of bleeding complications in patients on oral anticoagulants, as reported in 3

Considerations for Tramadol Use

• Tramadol has a recommended dosing adjustment and potential ceiling effect, which may limit its chronic use in patients with significant pain 2
• The use of tramadol in patients on oral anticoagulants may increase the risk of bleeding complications, with a pooled risk ratio of serious bleeding of 2.68 [95% CI: 1.45 to 4.96; p < 0.001] 3