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Gross Hematuria Case Study MEDICAL STUDENT CASE- BASED LEARNING
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Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Jun 27, 2018

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Page 1: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Gross Hematuria Case Study

MEDICAL STUDENT CASE-BASED LEARNING

Page 2: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Patient Presentation

57-year-old Caucasian male hospitalized UTI and gross hematuria

Page 3: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

HPI • 57yo man with a C6 spinal cord injury with quadriplegia

– Bladder managed with indwelling foley catheter changed monthly

– Went to PCP after noticing blood in the urine – Sent to ER and admitted to the hospital – Urine culture showed 3 or more organisms – Started on IV antibiotics – No fevers or chills – Gets 3-4 infections per year – Has been transfused 2U since admission this morning

Page 4: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

What additional history would be pertinent?

Page 5: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Patient: History & Physical Exam • Denies fevers or chills • No fevers, abdominal or flank pain • PMHx: C6 SCI at age 35, HTN, HL • PSHx: cystolitopaxy (bladder stone removal) 5y ago, neck surgery • Meds: baclofen, • FHx: No known history of stones or malignancies • SHx: Has fulltime aide, non-smoker

• PE: Mild abdominal tenderness and distension, no costovertebral

angle tenderness bilaterally, normal phallus with orthotopic meatus, foley in place draining red urine, dark urine in foley bag

Page 6: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

What are some drugs that can turn the urine red and mimic gross hematuria?

Page 7: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Drugs That May Cause Red Urine • Pyridium • Sulfamethoxazole • Nitrofuratoin • Rifampin • Ibuprofen • Dilantin • Levodopa/Methyldopa • Quinine/Chloroquine

Page 8: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

What is your differential diagnosis?

Page 9: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Differential Diagnosis

• UTI • Malignancy

– Bladder cancer – Upper tract

urothelial carcinoma – Renal cell carcinoma

• Urolithiasis • BPH • Non-infectious cystitis • Glomerulonephritis • Trauma

Page 10: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Hospital Course

• Hand irrigated the catheter any many clots obtained

• Changed to 3-way catheter and continuous bladder irrigation was started

Page 11: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Next Steps?

Page 12: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Lab and Radiology Evaluation

• Hematocrit 28.5 on admission – Hct was 36 at visit with PCP 1 month ago

• Creatinine 1.1 • PT, PTT, INR within normal limits • Cytology sent • CT Urogram

Page 13: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Non-Contrast Imaging

Page 14: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 15: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 16: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 17: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Delayed Imaging

Page 18: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 19: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 20: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 21: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 22: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 23: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 24: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 25: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 26: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 27: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis
Page 28: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

CT Results?

Page 29: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

CT Read • No uppertract defects

• Thickened bladder wall

• Copious clot debris in

bladder thought to be clot

• Large enhancing mass on posterior aspect of bladder

Clot

Mass

Page 30: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

What would be your next step in evaluating and treating this patient’s

hematuria?

What surgical procedure(s) would you consent this patient for?

Page 31: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Surgical Options • Cystoscopy • Clot evacuation • Possible transurethral resection of bladder tumor • Possible instillation of intravesical mitomycin • (No need for retrograde pyelogram as ureters were

visualized on delayed CT urogram imaging)

Page 32: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

What risk factors does the patient have that would predispose him to

urologic malignancy?

Page 33: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Patient: Risk Factors/Clues for Malignancy

• Male gender • Long term indwelling foley catheter (chronic

irritation) • Recurrent urinary tract infection (chronic

irritation) • History of bladder stones (chronic irritation)

Page 34: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

What are different types of bladder cancer?

Page 35: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Bladder Cancer Urothelial Origin • Transitional cell carcinoma

– About 90% of US cases

• Melanoma, colon, prostate, lung, breast

Non-Urothelial Origin • Squamous cell carcinoma

– About 5% of US cases – Chronic irritation (US) and

schistosomiasis (world) are primary risk factors

• Adenocarcinoma – About 1% of US cases – Bladder exstrophy is risk factor – Urachal cancers

• Small cell carcinoma, rhabdomyosarcoma, pheochromocytoma, lymphoma

Secondary Malignancies (mets)

Page 36: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

OR Procedure • Cystoscopy • 400cc of clot evacuated • No bladder tumor was seen • Trilobar prostatic hypertrophy with

very large intravesical median lobe

Page 37: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Could BPH cause this much hematuria?!

Page 38: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

YES! • Incidence of hematuria with BPH reported to be as

high as 12% • BPH causing gross hematuria requiring transfusions

occurs < 2% • Usually due to neovascularity in prostate adenoma • Can be treated with finasteride • Other treatment options: amicar, androgen

deprivation, surgery (TURP)

Page 39: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

How does the body help treat the large bladder clot?

Page 40: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Urokinase

• Urine contains urokinase

• Urokinase is an enzyme that promotes clot lysis by converting plasminogen to plasmin

Page 41: Gross Hematuria Case Study - American Urological … · gross hematuria . HPI ... • No fevers, abdominal or flank pain ... What is your differential diagnosis? Differential Diagnosis

Management

Prostate Chips

• Patient elected to undergo TURP for management of hematuria and BPH

• Primary resection of the median lobe