Item: ca ?Mark ~ [> !

f ~ ~ , ~
0. ld : 4751 Prev1ous Ne>tt Lab Values Notes Calculator Reverse Color Text Zoom

A 53-year-old man comes to the office due to occasional red urine for the last 3 months.
He states that his urine stream appears normal initially but turns red by the end of
voiding. He has also noticed small clots in his urine. The patient has not had any fever,
edema, flank pain, or weight loss. Medical history is significant for chronic back pain. He
currently smokes a pack of cigarettes daily but does not use alcohol. His temperature is
37.5 C (99.5 F) and .blood pressure is 160/90 mm Hg. Physical examination is within
normal limits. Urinalysis is positive only for blood. Which of the following is the most
likely cause of this patient's symptoms?

o A. Bladder disease
0 B. Glomerular disease
0 C. Nephrolithiasis
o D. Polycystic kidney disease
0 E. Urethral injury
o F. Urinary tract infection

Submit

~
------------------------------------------------------
Feedback Su~nd EnQock
Item: ca ? Mark ~ [> !f ~ ~ , ~
0. ld : 4751 Prev1ous Ne>tt Lab Values Notes Calculator Reverse Color Text Zoom

A 53-year-old man comes to the office due to occasional red urine for the last 3 months.
He states that his urine stream appears normal initially but turns red by the end of
voiding. He has also noticed small clots in his urine. The patient has not had any fever,
edema, flank pain, or weight loss. Medical history is significant for chronic back pain. He
currently smokes a pack of cigarettes daily but does not use alcohol. His temperature is
37.5 C (99.5 F) and blood pressure is 160/90 mm Hg. Physical examination is within
normal limits. Urinalysis is positive only for blood. Which of the following is the most
likely cause of this patient's symptoms?

A Bladder disease [79%]

B. Glomerular disease [8%)
C. Nephrolithiasis [3%)
D. Polycystic kidney disease [4%]
E. Urethral injury [4%]
F. Urinary tract infection [1%]

Proceed to Next Item

Explanation: User

Causes of hematuria

Hematuria throughout urinary stream:

• Renal mass (benign/malignant)
• Glomerulonephritis
• Urolithiasis
• Polycystic kidney disease
• Pyelonephritis
• Urothelial cancer
• Trauma
Explanation: User

Causes of hematuria

Hematuria throughout urinary stream:

• Renal mass (benign/malignant)
• Glomerulonephritis
• Urolithiasis
• Polycystic kidney disease
• Pyelonephritis
• Urothelial cancer
• Trauma

Upper collecting system

Terminal hematuria: Lower collecting system

• Urothelial cancer
• Cystitis (infectious/post radiation)
• Urolithiasis
• Benign prostatic hyperplasia
• Prostate cancer

Initial hemat uria:

• Urethritis
• Trauma (eg, catheterization)
@UWorld

Gross (ie, visible or macroscopic) hematuria can be classified based on the stage of
voiding at which bleeding predominates:
• Initial hematuria is characterized by blood at the beginning of the voiding cycle.
-- ····- - - · · - - -- --- ----- --- ---- --- - ---
Feedback EnQock
 • Urethritis
• Trauma (eg, catheterization)
© UWorld

Gross (ie, visible or macroscopic) hematuria can be classified based on the stage of
voiding at which bleeding predominates:
. Initial hematuria is characterized by blood at the beginning of the voiding cycle.
• Total hematuria is characterized by blood during the entire voiding cycle.
• Terminal hematuria is characterized by blood at the end of voiding cycle.

Terminal hematuria often suggests bleeding from the prostate, bladder neck or trigone,
or posterior urethra. In this patient, the presence of terminal hematuria with clots
suggests bleeding within the bladder or ureters and is concerning for urothelial cancer,
particularly given his risk factors of age (>40), sex, and smoking. He should be
evaluated for bladder cancer by cystoscopy.
(Choice B) Glomerular diseases can cause nephritic syndrome with microscopic or
gross hematuria. Patients can also present with total hematuria. However, clots would
be unusual, and urinalysis frequently shows red blood cell casts and may show
proteinuria.
(Choice C) Nephrolithiasis can cause hematuria. However, stones usually present with
flank or groin pain, depending on the location of the stone.
(Choice 0) Polycystic kidney disease is the leading heritable cause of renal disease in
adults. However, it usually presents as abdominal or flank pain with microscopic or gross
total hematuria and, occasionally, a bulky mass on abdominal examination.

(Choice E) Urethritis or urethral injury (eg, Foley catheterization) typically manifests as

initial hematuria.
(Choice F) All urinary tract infections (pyelonephritis, cystitis, urethritis) may present
with microscopic or gross hematuria. However, pyelonephritis usually presents with flank
pain and systemic illness (eg, fever, nausea, vomiting); cystitis and urethritis present with
irritative voiding symptoms (eg, dysuria, urinary frequency, hesitancy).
Educational objective:
Initial hematuria suggests urethral damage, terminal hematuria indicates bladder or
prostatic damage, and total hematuria reflects damage in the kidney or ureters. Clots are
not usually seen with renal causes of hematuria (eg, glomerular diseases).

Time Spent: 3 seconds Copyright© UWorld Last updated: [07/29/20 16]

 Item: "'?Mark ~ C> ! t ~ ~ , ~
0. ld : 4751 Prev1ous Ne>tt Lab Values Notes Calculator Reverse Color Text Zoom
Media Exhibit

ions for cystoscopy

Indications for cystoscopy

• Gross hematuria with no evidence of glomerular disease

or infection
• Microscopic hematuria with no evidence of glomerular
disease or infection but increased risk for malignancy
• Recurrent urinary tract infections
• Obstructive symptoms with suspicion for stricture, stone
• Irritative symptoms without urinary infection
• Abnormal bladder imaging or urine cytology
© UWortd

! Hematur i a - ~~~ Q
I Renal, Urinary Systems & Electrolytes Feedback End Block