Dear Sumner:
How do you handle a 62 year old man with red urine? Harry, who I has been my patient for 22 years, told me during his yearly routine checkup that for the past 6 months or so he has noted a reddish discoloration of his urine. Since this was intermittent, lasting only for one or two urinations and he had no associated discomfort, he figured that there was nothing seriously wrong and saw no need to call me earlier. I didn’t want to alarm him, but, quite frankly, I am, indeed, worried about a possible serious problem. (I seem to remember from my medical school days that with gross blood in the urine a tumor somewhere within the urinary tract must be ruled out. Am I correct in this assumption? I suggested he call your office for an appointment for the very near future.
Dear Ben:
First of all, thanks for encouraging Harry to see me so promptly. Statistically speaking, hematuria is more likely to be secondary to a benign process such as from an inflammatory/infectious process or a stone, although I always worry about the possibility of a tumor within the urinary tract. Of course, it is possible that the reddish discoloration of his urine was secondary to dye or some breakdown products in medication or foods rather than from blood. When I checked Harry’s urine today, I did not find any red blood cells in either the urethral washings or mid-stream urine samples. However, that does not mean he didn’t have them before, and with the history as presented, I feel that Harry’s urinary tract should be visualized via some radiological study and urine examined for abnormal cells (cytology). (I have a general rule that every patient with hematuria be it gross or microscopic only, gets a minimum of a renal/bladder ultrasound and urine for cytology; with gross hematuria, I will add cystoscopy to the workup).
If there is anything suspicious noted on the renal ultrasound, or if the urine is subsequently found to contain red blood cells, or if the urine cytology shows any abnormal cells, then I will follow with an intravenous pyelogram (IVP).
Dear Ben:
The renal/abdominal ultrasound study showed no gross abnormalities and the urine cytology, no abnormal cells. However, I subsequently found red blood cells in both the 1st and 2nd glass urines, suggesting their source to be proximal to the bladder neck, i.e. from the bladder, ureters or kidneys. I did obtain a CT scan which, happily, revealed no obvious tumors or enlarged lymph nodes. On cystoscopy, however, I found a sessile lesion which had the gross appearance of a low grade tumor and, indeed, on histological examination that diagnosis was confirmed. (By the way, Ben, a negative cytology does not rule out the presence of a tumor, only that, if a tumor is present, it is likely low grade and probably not invading the deeper layers of the bladder wall). I will be looking in Harry’s bladder at three month intervals for one year and then at increasing intervals thereafter. Should there be multiple recurrences, and then consideration would be given to the use of intravesical therapy, such as chemotherapeutic or immune boosting agent. Hopefully, the use of such will not be necessary. Generally in cases of superficial tumors of the bladder, the overall prognosis is quite good
