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Old 11-01-2012
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Urine Sample Asymptomatic Hematuria; Next best Step!

adult patient presents with asymptomatic gross hematuria . what is the most apt next step in mx of this q ?
USG to rule out RCC or cystoscopy to rule out bladder cancer and please give expln ! i think this is super hy.
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Old 11-01-2012
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Asymptomatic Gross Hematuria should be considered maligancy in adults unless proven otherwise. I think first step was to do a contrast CT or IVP and then cystoscopy. I don't think we do USG first.

Source - Uworld
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Old 11-01-2012
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Its depends on clinical vignette

Flank pain hematuria flank pain and flank mass --- Renal cell carcinoma- USG abd.

Gross hematuria with clots -- Cystoscopy
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Quote:
Originally Posted by cingulate.gyrus View Post
Its depends on clinical vignette

Flank pain hematuria flank pain and flank mass --- Renal cell carcinoma- USG abd.

Gross hematuria with clots -- Cystoscopy
I agree but he said ASYMPTOMATIC. Answer is what I wrote above. I just checked again.
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If its an adult with gross hematuria and risk factors like smoking and all that crap then you have to work out the 3 top causes of gross hematuria in adults which are
Renal cell carcinoma
Bladder cancer
Urethral cancer

You start by ruling out the upper GU system and then the lower, that is do an IV Pyelogram/CT scan of the pelvis and then a cystoscopy to rule out bladder cancer.

The most common malignancy of those 3 is Bladder Cancer.
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Depends on the age, history (smoking, occupational exposure to chemicals or dyes (e.g., benzenes, aromatic amines)) and other pointers.

However, asymptomatic gross hematuria (with clots) in an elderly is Bladder Ca unless proven otherwise.

Asymptomatic gross hematuria in an younger adult (without clots) points more towards RCC especially if classic clues like left sides Varicocele, polycythemia, pulmonary embolism without a discernible source DVT are present.

Also, you can have a fair idea how to proceed based on the characteristics of hematuria itself.

Quote:
The characteristics of the hematuria can often help distinguish the cause and location of bleeding. A glomerular source of bleeding usually results in persistent microscopic hematuria, with or without periods of gross hematuria. In renal sources of hematuria, the blood is equally dispersed throughout the urine stream and does not clot.6 If clots are present, it is important to ascertain where in the urine stream they occur. Hematuria or clots at the beginning of the urine stream, initial hematuria, is a symptom of a urethral cause. Terminal hematuria, occurring at the end of the urine stream, may occur with a prostatic, bladder, or trigonal cause of hematuria.
Quote:
Another helpful practice in locating the source of bleeding is the three-tube test. Three consecutive samples of the urine stream are collected—the first few milliliters, midstream, and the last few milliliters. Similar to that described for the location of clots in the urine stream, hematuria primarily in the first sample is consistent with a urethral source, whereas hematuria primarily at the end of the urine stream is more likely a lesion at the bladder trigone. Equivalent hematuria in all three samples is seen in renal, ureteral, and diffuse bladder lesions.
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Quote:
Originally Posted by Novobiocin View Post
Depends on the age, history (smoking, occupational exposure to chemicals or dyes (e.g., benzenes, aromatic amines)) and other pointers.

However, asymptomatic gross hematuria (with clots) in an elderly is Bladder Ca unless proven otherwise.

Asymptomatic gross hematuria in an younger adult (without clots) points more towards RCC especially if classic clues like left sides Varicocele, polycythemia, pulmonary embolism without a discernible source DVT are present.

Also, you can have a fair idea how to proceed based on the characteristics of hematuria itself.
thanks novo but as per uworld, urethra \ prostate injury causes initial not terminal hematuria
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Originally Posted by tyagee View Post
thanks novo but as per uworld, urethra \ prostate injury causes initial not terminal hematuria
That what I said. Read the quoted text again.
The text you quoted is for asymptomatic hematuria. Urethral/prostatic injury will be symptomatic.
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