A 65-year-old man presents with a 3-month history of intermittent, recurrent, painless visible haematuria. He is a smoker of 10 cigarettes a day and has a previous medical history of hypertension (controlled on ramipril), obesity and an open appendectomy aged 21. On examination he has no abdominal masses, normal external genitalia and a smooth, mildly enlarged prostate. His dipstick urinalysis shows trace of protein and 3+ blood only and midstream urine cultures are sterile. His uroflowmetry reveals a Qmax of 18 mL/s and a post-void residual of 15 mL. His routine blood tests are normal.
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1. What are the causes of haematuria?
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Correct answer:
- Infection: of any part of the urological tract; commonly cystitis or pyelonephritis but also including urethritis from a sexually transmitted infections (rarely, tuberculosis or schistosomiasis)
- Tumour (kidney, urothelial (collecting system/ureter/bladder/urethra), prostate (benign prostatic hypertrophy; prostate cancer rarely causes haematuria), other bladder cancers (adenocarcinoma, squamous cell carcinoma)
- Calculi: stones in the kidney, ureter, bladder or, rarely, urethra
- Trauma
- Iatrogenic: following any instrumentation including catheterisation
- Inflammatory: painful bladder syndrome (interstitial cystitis), prostatitis
- Renal: nephritic syndrome
- Blood disorders: sickle cell disease, clotting disorders, anticoagulant and antiplatelet drugs
- Idiopathic: benign familial haematuria, athletic nephritis, march haematuria
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2. What is the relevance of his previous medical history?
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Correct answer:
- Smoking is a risk factor for urothelial cancer and renal cell carcinoma.
- Hypertension and obesity are risk factors for renal cell carcinoma.
- Sixty-five year olds are in the peak age category at risk of bladder and renal cancers.
- All urological cancers are more common in men.
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3. What are the risk factors for urothelial cell carcinoma?
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Correct answer:
- Smoking is the main risk factor in the modern western world
- Industrial dye exposure
- Male sex
- Chronic infection.
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4. What initial investigations should be considered in this man?
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Correct answer:
- Upper tract: ultrasound scan + intravenous urogram or CT urogram
- Lower tract: cystoscopy: flexible (can be performed under local anaesthetic) or rigid (which typically requires a full anaesthetic).
Urine cytology is not routinely used initially because of its low sensitivity.
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5. If flexible cystoscopy demonstrates a 2-cm lesion at the dome of the bladder (likely malignancy), what should the next steps of his management be?
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Correct answer:
- Urgent transurethral resection of bladder tumour (TURBT)
- CT urogram.
Urine cytology is not routinely used initially because of its low sensitivity.
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6. If flexible cystoscopy is normal and an ultrasound scan abdomen demonstrates a 4-cm upper pole complicated cystic renal mass, what should the next steps of his management be?
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Correct answer:
- Urgent CT renal protocol (triple phase, contrast enhanced) and chest
If this demonstrates organ confined disease he should go on to have surgery (either radical or partial nephrectomy via the open, laparoscopic or robotic-assisted laparoscopic route)
