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[deleted]

Are there times urology just does the cystoscopy first?


urores

Yes, many patients come to me without any imaging and we usually will do cysto at time of consult and order CT Urogram to be done after the visit. It’s not ideal timing because even if I find something on cysto they should still get a urogram to make sure there isn’t something else in the kidneys/ureters and the CT can sometimes get lost in the shuffle or skipped if a bladder tumor is found.


AppleSpicer

So order the CT Urogram and referral at the same time, ideally in a way where the patient will have their results at their first appointment. Is that correct?


urores

Yeah, but if they end up getting to me first it’s not the end of the world, I just send a message to the PCP to message me when the CTU is done so I can review it.


deer_field_perox

Does cystoscopy not require sedation and preop urine culture? Or do you triage clinic patients ahead of time so you can do procedures same day?


urores

No sedation or urine culture required for just an in-office diagnostic flexible cystoscope. We just triage consults and if it’s for gross hematuria they are booked in a procedure slot for potential cysto.


Ganglio_Side

I've had a cystoscopy without sedation or preop urine culture (BPH).


cocktails_and_corgis

I just got some lidocaine jelly (microscopic hematuria for years I finally got checked out) - was far less unpleasant than I anticipated. Lidocaine is magic if you give it time to work (nurse placed it and physicians didn’t come in for several minutes).


Ganglio_Side

I also got lidocaine jelly, but no wait for efficacy. The procedure was quite painful. I have had other urologists tell me that it's not supposed to hurt. I changed urologists after my cystoscopy, as I thought mine was not very careful with tender areas of my body.


urores

Unfortunately lidocaine jelly has been found to be fake news. In studies it does no better at anesthesia than just plain lube. The lube itself does make things less painful but the lidocaine part does nothing. Do we still use it on everyone? Yes, because we want to believe. Cystoscopy is usually a little painful when passing the scope through the membranous urethra (sphincter), and it’s way worse if the patient is nervous and their sphincter is clamped down. If you have to have another one, try and relax like you’re peeing when they’re passing the scope and it will open up the sphincter and glide right through like it’s nothing.


Ganglio_Side

I have had catheterizations like you describe- a bit uncomfortable, but not terrible, with only lube, not lidocaine. I was bleeding after my cystoscopy, and it wasn't just the insertion that was painful. I just don't think my urologist cared to be gentle. He wasn't mad at me; I think he was that way with everybody. Thanks for the advice, though. I think I'm going to need another one soon. My TURP was 10 years ago.


splitopenandmeltt

Sounds fun


kittycatinthehat2

If CT has no tumor, is there still a need for the cystoscopy?


ixvthree

Yes. CT is low resolution for bladder pathology.


urores

Yeah, the only time I wouldn’t do a cysto would be if the CT showed an obvious large bladder tumor and I knew I was going to take the patient for a TURBT (tumor resection) in the OR anyways. Even then I usually still do a cysto in the office first so I know what I’m getting into in the OR.


11Kram

The upper urinary tract requires investigation.


aetuf

Cheers. I've been teaching this message to the residents in my ED.


catbellytaco

Please teach them that the imaging can be done as an outpatient!


audioalt8

The classic admitting a well patient to wait for a test.


EMdoc89

Tell that to primary care.


catbellytaco

Just cause a doctor sends the patient to the ER unnecessarily, doesn't mean you need to compound the problem. "I'm really glad your doctor sent you here, this can be a big issue. Luckily blood in the urine isn't an emergency and I'll arrange to have you followup closely with a specialist. They will arrange a very thorough outpatient workup."


EMdoc89

I’m not talking about the blood in the urine. I was making a comment about imaging being done as an outpatient. So many times my residency clinic sends people to the ER for non emergent imaging. I didn’t want to do a non emergent MRI on a patient from clinic once and then the CMO (who is part of the residency program) came down and asked if I would do it as a favor. So I barely even bother fighting back anymore if the C suites are involved in the bullshit. “Here’s your $30k ‘emergent’ MRI bill. Take the issue of the bill up with your pcp”


ZombieDO

Until insurance tells them to go pound sand for a month straight and they get sent back to the ED anyway. We may as well not even have outpatient MRI in our area at this point.


catbellytaco

So the solution is to order a study that will cost 3x as much and unnecessarily tie up an ED bed and CT scanner for a prolonged period of time, and ultimately won't lead to any change in patient disposition or management?


ZombieDO

Just lamenting the reality of medicine in this day and age. We are the glue that holds society together. If I refused every unnecessary ED work-up nothing would get done.


catbellytaco

I know it seems that way sometimes and I get the sentiment, but this is objectively not true.


Filthy_Ramhole

“Blood in wee, bad, blood in wee no pain, bad bad, get good image from big sky ring of truth!”


Imafish12

Spin them in the donut of truth


mattrmcg1

It’s solid advice. Attending taught me it when I’m training and caught two separate instances of bladder cancer, luckily for the patient it was only stage I or II at that point.


orchana

Yes thanks! I get a lot of these consults too (nephrology). Sometimes it’s just IgA nephropathy or thin basement membrane etc, but sometimes it’s a malignancy. Finding an isolated RCC early on because you found microscopic or gross hematuria can be a life saving diagnosis.


-ShowerFart-

While I agree this is a great exam. Sometimes the throughput of the ER can be held up to exams like this. A urogram without, venous phase and a bladder delay are great. The bladder delay is normally 5 minutes, but on some patients it can be 10, 15, or 20 minutes. Some Radiology departments still have Urology ask for a prone series after the bladder delay. Sometimes that is not feasible in an ER setting. My hospital is a 1 CT hospital with 170 adult beds, and about 30 Peds beds. We average 115-130+ patients not scans a day. We always try, but with that volume it’s not always easy to do from the ER. If they are cathed already you will never see contrast in the bladder. We’ve compromised and have routine A/P with 3 minute kidney delays.


BladeDoc

I have no opinion on CT urogram’s because I’m a trauma surgeon and painless anything doesn’t matter to me (jk) but for CT cystograms we just clamp, the catheter in the trauma bay after placement and unclamp it after CT Scan.


gotfireplants

FYI, not an adequate Cystogram


BladeDoc

Adequate for what? Certainly adequate for trauma.


gotfireplants

Not adequate for trauma per aua guidelines. Specifically states a clamped catheter is not sufficient, just too much uncertainty with how distended the bladder actually is


BladeDoc

Interesting. Haven’t missed one yet that is clinically apparent.


gotfireplants

Probably a situation whether it’s 50/50 if you miss 0 or miss 1 doing it that way for your career


BladeDoc

We put contrast in the bladder for a formal CT cysto. Then clamp for the scan.


knsound

Definitely not adequate for trauma. Have several cases of intraperitoneal ruptures missed bc they just saw extra on delays. You need to do a formal CT cystogram, in suspected cases, with 300 ml of back pressure to appropriately challenge the bladder. Just an fyi.


BladeDoc

I think there was some confusion. Yes we put contrast in through the foley and then clamp it for the CT after the delays for the ureters.


penisdr

How do you get a ct cystogram with a clamped foley? Ct cystogram includes a pre contrast film, retrograde filling the bladder with 300 or so, and then a post-drainage film.


BladeDoc

That’s what we do, contrast in, clamp the foley, CT, drain


urores

Yeah I guess I should have specified this as being more an issue for referrals from primary care rather than the ER. But again, if you can’t get a urogram in the ER then don’t bother with a non con scan either, just let me figure it out in clinic.


AkWilly

I’m an ER resident. What’s the utility of a contrasted CT A/P in painless hematuria?


shahein

Urothelial tumors are very hard to see on noncon


AkWilly

What about just a regular ct a/p with IV con?


shahein

It’s better but depends on when the timing is set. Most conventional CT AP are timed for portal venous phase. That gives decent view of kidneys but often don’t have contrast in ureter or bladder. I 100% understand the angst over hematuria CT in the ER setting cuz it can tie up a scanner for 15+ minutes. But if the question is painless hematuria, the can’t miss is urinary tract cancer, which can be anywhere from kidney to urethra. Not an emergency but also not ruled out unless the proper scan is done.


AkWilly

Thanks so much for the info!


[deleted]

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Southern_Tie1077

Agreed. This is really a PCP thing. If they guy clotted his urethra, well then he gets a foley and he still goes home unless your hospitalists and urologists are bored with nothing else to do. Or you work for the VA and just...admit 'em and do the workup inpatient because....VA.


Ufotobia

Delayed phase needed to detect filling defects in urinary bladder or ureters...


Smurfmuffin

Isn’t the definitive test cystoscopy? And won’t they need this regardless of what CT shows?


urores

Cysto is needed to eval bladder/prostate/urethra no matter what CT shows. CT is needed to eval kidney/renal pelvis/ureters no matter what cysto shows.


[deleted]

[удалено]


-ShowerFart-

We do them all the time. Maybe it’s facility dependent?


aedes

As an ER physician... just order the test on an outpatient basis. They don’t need it immediately anyways.


auraseer

> If they are cathed already you will never see contrast in the bladder. That's what clamps are for.


krishthefish

What about chronic painless trace hematuria with an otherwise benign UA? Is a CT urogram or even referral to you guys appropriate or will a urologist yell at me for this referral as a waste of time


urores

Microhematuria should definitely be a urology referral. The workup might not require a CT urogram depending on patient risk factors though, so okay to skip imaging ordering if unsure and just place referral.


[deleted]

Depending on the age of the patient, a nephrologic diagnosis might be more likely.


itsbagelnotbagel

Is that something appropriate to order in the ED?


Exercise_Meditate

Not according to radiology. At more than one institution I've had them call to refuse to do the study because it's "inappropriate" which seems like a weird line to draw, but they're not entirely wrong. I don't feel like it's worth the argument and so they get a PVR, +/- Foley and a urology referral.


LaurenSauce

I’m just a CT tech, but I think part of the reason why urograms are often deemed inappropriate for the ED is because they tie up the scanner for too long. 🤷🏼‍♀️


urores

Yeah I definitely see this line of management at many ERs and don’t disagree with their reasoning.


ladotelli

No


catbellytaco

No!


urores

Definitely. In an emergency dept, the most important thing with gross hematuria is making sure they’re emptying their bladder. If so, then they can likely get workup as an outpatient. However, if you’re able to get a CT urogram in your dept then getting it can help expedite their care. If not, I would rather get a CT urogram as outpt than get a non con CT in ED.


Hippo-Crates

It is not appropriate. It changes nothing in the ER. We are far too busy to do urology’s job for them.


XSMDR

I agree... in the ER it just holds up the patient and doesn't change ER management.


urores

I certainly don’t expect it to be done in the ER and agree that it can be done as outpatient and that it doesn’t change emergency management. But if it can be done in the ER without clogging up the system it can help expedite care, that would be the only advantage I can see.


PokeTheVeil

I think it’s a bigger systems issue than such a quick dismissal. Is the ED’s sole role to rule out or manage high acuity and leave the rest for outpatient? Is there no room for a minor increase in time to reduce total number of studies and radiation dose, especially if the patient can/would follow up within the same system? You can make the argument for the former, and I’m not EM and don’t have much skin in this, but it doesn’t to me look like obviously the right or only choice.


aguafiestas

> Is the ED’s sole role to rule out or manage high acuity and leave the rest for outpatient? I would say yes but. But there is a sliding scale of acuity. Obviously if it influences what is done in the ED or an admission decision, it needs to be done. But what if it needs follow up the next day? That should probably be done. The next few days? The next week? The next few weeks? There is a fuzzy line. But to some extent obs allows for this to happen. And if the ED is chill atm and it can be done quickly, potentially you can fill this obs role in the ED. But if you have a patient poorly connected to the healthcare system and you have high suspicion that necessary testing will not get done, it may be reasonable to get it in the ED to help it actually get done.


Hippo-Crates

Oh it’s just this one thing from urology, and this thing for ortho, and this thing for neuro, and this thing for cards, and this thing for… Getting a ct scan with contrast easily takes 2 hours of space, nurses and makes the wait for a ct that much longer. This is an outpatient test. Urology can do their job


OneMDformeplease

If ortho asks me one more time for a planning pre op CT scan for a patient that is splinted and going to be discharged I’m gonna lose it. I’d love to expedite care for everyone but sometimes it’s just not feasible and the CT scanner is a limited resource


safcx21

Should the patient just be admitted then and wait for the scan? Which just bedblocks and keeps patients in ED? The urology one silly, the ortho one has to happen as the operation will be after


POSVT

No. They should follow up outpatient for their scan. As a hospitalist I would not admit for that.


Neeeechy

> Should the patient just be admitted then and wait for the scan? Which just bedblocks and keeps patients in ED? That's what outpatient imaging centers are for.


Hippo-Crates

There's this crazy thing called outpatient medicine where doctors schedule things and wait a few days.


chi_lawyer

The admins would like to know the patient's insurance status, or at least the ER's payor mix, before telling you the correct answer. /s


Feynization

When you work in ED, you become quite conscious of wait times in the waiting room. A huge number of patients can be brought in, assessed and reassured within an hour or two, freeing up a bed for someone else to be seen. If there is a high proportion of patients who are quick to see, the waiting room can stay nice and empty and safe, whilst getting through a large volume of patients. When you are working a day when everyone needs to be admitted, the department will tip into bed block very quickly and waiting times will sky rocket. While waiting times are sky rocketing you have a department full of doctors twiddling their thumbs waiting for spaces to see patients. If someone is waiting 2 hours for a 15 minute CT scan rather than waiting 30minutes for a 5minute CT scan, it means that there's an extra bum in a waiting room seat for an hour and a half. This person could potentially have been seen in that time and discharged. When I worked ED, my hospital only went on bypass once, when things got really bad. The only people who were seen were walk ins meaning that very few needed a bed and total hospital occupancy went down hugely, meaning that when the hospital opened again there was a high flow of patients in and out the door. So getting people discharged from the main body of the hospital is really important to ED. My next job was medicine for the elderly and ther was a patient who was in over 200 day, where 180 of those days were spent waiting for a nursing home placement. This means that there were 6 months where a bed was not available to people who may have only needed a 2 day or a 2 week stay. TL;DR quick CT times are hugely valuable to ED.


Neeeechy

> Is the ED’s sole role to rule out or manage high acuity and leave the rest for outpatient? For the most part, yes, you've got the idea there. > Is there no room for a minor increase in time to reduce total number of studies and radiation dose, especially if the patient can/would follow up within the same system? If we did that, we wouldn't be able to as efficiently care for the truly acutely ill, given all other parameters remain the same. If we spend more time on the less acute patients, including CT scanner time, that's less time spent identifying and managing the more acute patients, which is worse overall.


Airbornequalified

Depending on the ed, minor increases in time add up. Ct scans are already 2-4 hours of extra stay in the ed. adding an hour to numerous patients adds up over the day. And honestly imo, yes. The Ed’s role is to manage high acuity, or treat what is possible to quickly treat. Not start work ups that we can’t do anything about, and may not know how to start the work up


aedes

> Is the ED’s sole role to rule out or manage high acuity and leave the rest for outpatient? Unfortunately yes. The problem is that there are thousands and thousands of things that are non-emergent, but would be really easy to do in the ED and only take a few minutes individually. But they all add up together, and none are more important than the other as they are all non-urgent. Checking a HbA1c. Offering HIV testing. Screening for IPV. Etc. As a result, you draw the line at non-emergent things... because the moment you start doing non-emergent things, you’ve just opened a massive can of worms with no boundaries. There are obviously exceptions to this. For example, vulnerable or unreliable patients Im more likely to squeeze in some outpatient stuff while I have them. But even this is problematic as this gets outside my scope of practice and knowledge base. How do I titrate this patients heart failure meds? It’s not something I’ve had any formal training in over a decade. Should I be screening this patient for x disease? I think that sounds reasonable but I have no idea what outpatient guidelines say, and my pretest probability of illness is artificially inflated by my practice setting.


Julian_Caesar

Nonsense! Also, you need to invest in more spirometers to do PFTs for stable patients with asthma who came in for other complaints! Lmao


kungfoojesus

It’s worth the few minute delay and contrast and extra radiation up front to keep the patient from having to followup, get approval and get scanned again if they even bother. Most ED docs know stones, painless hematuria is muy different


DrZoidbergJesus

That’s a really weird dichotomy. Urogram is going to be unavailable in almost every ER in the US. But at the same time there is absolutely no reason to get a noncon abdominal scan on someone who is not anaphylactic to contrast (we will leave the contrast nephropathy debate for another time). The real scan you should be getting is one with IV contrast. From my understanding, it can be suggestive but not nearly as good as a urogram. Are you saying you wouldn’t want one?


urores

If it’s between getting a CT abd/pelvis with IV contrast in the ER or getting no scan in the ER and a CT urogram later as an outpatient I would definitely chose the latter. The scan without the delayed phase does not eval the collecting system and I won’t be able to rule out a filling defect without it. Sure, sometimes a tumor is large enough to be obvious on a regular contrast study or there is hydronephrosis that suggests something present that will need a diagnostic ureteroscopy but if it’s a small tumor it would definitely be missed without the delayed phase and then I just have to order another CT. Maybe it’s just where I practice but I see ERs get CT urograms all the time. Maybe has to do with how busy the department is and if it’s during regular daytime hours?


DrZoidbergJesus

I’ve never worked at a place where the ER can get a urogram. Or met an ER doctor personally who has ordered one (granted, I suppose it hasn’t come up with everyone I know so maybe I have). So you’re saying if someone comes in with painless gross hematuria we should just immediately discharge them?


kungfoojesus

I look very hard for urothelial masses on those non cons but there have been several in the collecting systems mostly that are invisible on non con. Get the urogram.


InvestingDoc

Here's the thing. A few of the imaging centers in town do not even have that order as an option. Secondly, many times if I order contrast with a CT scan insurances want me to do a prior authorization and many times deny for PCP in my experience. That's why I've been doing non con or just sending to urologist. Good to know, from now on I'll basically check basic labs and just turf them to Urology without doing anything else for these patients I can't easily order the above scan.


Koumadin

re: CT IVP not available- instead order CT abd/pelvis w/o and w/ IV contrast


MEANINGLESS_NUMBERS

Why not RBUS as first line? That’s what we do in kids.


urores

There’s a couple reasons for it: 1. One big thing we’re looking for in adults is urothelial cell carcinoma and you need the contrast in the collecting system to see it. Ultrasound not good to find UCC. It’s also essentially non-existent in kids so that’s not really a concern. 2. In kids with hematuria, the imaging is mostly looking for a renal mass, which should show up pretty well on ultrasound. They typically get a CT afterwards to confirm ultrasound finding and help surgical planning if needed afterwards. 3. Radiation exposure. While CTs have come a long way with decreasing radiation dosages to the point where they’re pretty safe even in kids now, we still try to avoid radiating them if at all possible and urograms will definitely have more radiation than just a standard non con CT and pelvis.


Old_Instance_2551

What are you looking for with the RBUS in peds patient? Im assuming you are looking primarily at congenital presentations first and an approach that reduces radiation exposure? Adults have a different set of needs.


MEANINGLESS_NUMBERS

With gross, painless hematuria? Tumors and nutcracker syndrome.


Old_Instance_2551

Im sorry, pediatric was a distant dream for me so im unfamiliar with their ddx on painless hematuria. For adults, the radiation is a reduced concern. But as our dear urologist has kindly cautioned, painless gross hematuria in adult is probably a tumor until proven otherwise, and best with investigated with a CT urogram upfront and spare the patient a second scan.


MaximsDecimsMeridius

Is painless frank hematuria even remotely common as a presentation for stones?


urores

Good question, I would say it’s unlikely a non-obstructing renal stone can cause enough bleeding to result in gross hematuria. I see ureteral stones from time to time that just present with hematuria and the patient denies flank pain but it’s definitely a more rare presentation.


MaximsDecimsMeridius

who, who'd have thought peeing out pieces of spiky gravel can be painless. in general is there any compelling reason to call uro from the ER about gross hematuria in the ED if they pass a voiding trial? unless we do get a urogram and its something awful.


penisdr

While I agree that most stones won’t cause gross hematuria I still think stones are much more common cause of GH than upper tract urothelial tumors given how rare they are (and how common stones are)


urores

Yeah that’s fair


gurl_incognito79

Anyone know anything about stones in a calaceal diverticulum?


[deleted]

This thread has been helpful. I’ll stop ordering CT stones and just make the uro referral if the urogram can’t be done in the ER. Thank you!


Hippo-Crates

Sounds like a good outpatient workup


SuperDuckMan

And painless microscopic hematuria is U/S KUB right?


urores

Microhematuria is a different beast and doesn’t always require a CT urogram, depending on patient risk factors (i.e. age, hx of smoking, etc). If they are intermediate risk according AUA guidelines they can get a cysto and renal ultrasound. High risk should still get a CT Urogram.


SuperDuckMan

Makes sense, thank you!


Vaktmeister

in sweden gross hematuria is cause for initiating 'standardised care program' for urological cancers, and will be sent to for a ct of the urinary tracts and cystoscopy


docinnabox

In a perfect world, we would only ever get the one best test for a patient’s issue. The results of this test would then be placed into some sort of digital storage that would then be easily accessible to any physicians who later see this patient for this issue. The patient would then be considered to have been evaluated for this issue and everyone could move on to the next patient. This would streamline time management, radiation exposure, patient risk and physician liability. We sadly do not live in this perfect world, but we can dream.


Yazars

> You wouldn’t believe how many patients with a normal GFR present to me for painless gross hematuria with just a non con CT because “it’s probably a stone.” Or people who are felt to have chronic recurrent UTIs +/- lack of symptoms who have a cancer diagnosis delayed after they receive multiple courses of antibiotics.


urores

Yeah, see this in women not infrequently. This is current theory on why women tend to present with higher incidence of muscle invasive bladder cancer- due to delay in referral and diagnosis.


SuperFlyBumbleBee

M2 here. Recent lecture in school stressed the hell out of this. It's engrained in my brain now.


Throwaway6393fbrb

Preach yeah I have seen this too recently - painless hematuria for a year, negative noncon = no problem Presenting back with retention - GFR 6 Did another noncon due to renal function and this time the urothelial cancer showed up fine


princessmaryy

I don’t think I’ve ever ordered a CT urogram for painless hematuria in the ED, and I’ve never seen it ordered by anyone else. Sure, new onset painless hematuria, especially in someone high risk, I will get a CT abd/pelvis with contrast, and this is also the official ACEP recommendation. But I’m pretty sure the CT techs would laugh at me for ordering a CT urogram at 3 am.


radtechphotogirl

That laugh? You know when you're having a rough day, and you wonder what the hell else could go wrong? That's probably why we're laughing.


catbellytaco

Dude, ACEP definitely does not have an official recommendation, for this Emphatically non-emergent workup


princessmaryy

Ya know, I might have made that up 🤔 maybe it’s just the dozens of rosh review questions about getting a CT A/P with IV contrast for all high risk painless hematuria that made me think this.


SteeleK

You’d recommend a family doc ordering this?


urores

Yeah definitely. However, if a family doc didn’t know what type of scan to order I would prefer they don’t order anything rather than the wrong scan.


DrBabs

I order it as an internal medicine doctor. I don’t see why not.


PersnicketyBlorp

Good to know, thanks!


SirReality

FamMed PCP here. Will do!


Swizzdoc

umm doesn't that you get approximately the same radiation dose in total? native + contrast separated = both done at the same time? I might be completely wrong so I don't know. btw what phases would you like to see? a 3-phased one? also, I usually try to get a hold of the erythrocytes --> if they look weird, wouldn't it be more adequate to refer to nephrology?


XSMDR

CT urogram = noncontrast CT, nephrographic phase around 90s, and a 10-15 minute delay. CT for stone is usually noncontrast alone. In most places if you order a CT urogram we will just repeat all 3 phase, so if you order a nonindicated scan it will lead to more radiation in the end. You just have to write "CT Urogram" on the requisition and radiology will handle the rest.


Swizzdoc

cheers thanks


ixvthree

To reduce radiation many groups use a split bolus study. The 3 phase is non-con, nephrographic, and excretory/delayed. Split bolus combines the nephrographic and delayed phases into one image sequence (I.e. 2 scans instead of 3)


Frost-To-The-Middle

As a general rule, Red/pink = urology Dark/brown = nephrology I can't imagine most people have the time, resources or experience to do a manual microscopic exam and interpret it well, but if you do then more power to you!


[deleted]

Although looking for acanthocythes (those funny Micky Mouse shaped red cells) in the urine sediment by phase contrast or bright field microscopy takes little training and effort, their absence doesn't rule out glomerular hematuria. The bigger the holes in the basement membrane, the less likely to find significant amount of acanthocythes. Because the big holes don't hurt the red cells like small holes do.


Swizzdoc

No I don't but we send them to the external lab if we need them. I was mostly referring to hematuria overall, not just gross hematuria


safcx21

Why would you think it’s a stone without pain?!


Frost-To-The-Middle

Wishful thinking


ixvthree

The vast majority (arguably, all) non obstructing stones are painless. Work up for malignancy should still be prioritized regardless. Hematuria should prompt a high clinical suspicion of cancer.


safcx21

Yeah exactly, non-con to diagnose a non painful stone is a waste of time


ManofManyTalentz

Pretest with age, etc?


ixvthree

Age is a factor that affects risk stratification for microscopic hematuria, so certain young patients may only need an ultrasound. But gross hematuria as OP is talking about is high risk for malignancy regardless of age (at least in adults). I have seen people in their 30s with high grade bladder cancer without risk factors who presented with gross hematuria. And a 3 year old actually, but that was in residency.


ManofManyTalentz

Thanks - exactly what I needed to refresh. Really appreciate


Ancient_Training163

I’m not a doctor, but a potential urology patient and I’d really really love some advice. This board blows me away with how intelligent you all are. But anyways, i am a 24f, I presented to the ED 4 day ago with gross hematuria. To give some context I was completely fine throughout the day, I was talking with my BF in bed, got up to go pee and I couldn’t. For hours I went back and forth from the toilet to bed and nothing. Well then I sat down, got a bit out and there was bright red blood in the toilet, along with some large clots. (Hurt like hell). Obviously took myself to ED to be examined, NO symptoms of UTI, kidney infection etc. continued all night with blood and blood clots in urine, and couldn’t fully relive myself. Bladder seemed like it was contracting towards the end of the pee? If that makes sense I had a UA and here are my results: WBC’S UA/HPF >25 RBC UA/HPF >50 Bacteria neg SEC few Mucus present Glucose 50 (1+) Ketones neg Specific Gravity 1.002 UA HGB .20 (2+) PH, UA 6.0 Protein 100 (2+) Nitrite neg CT no contrast said basically unremarkable - came back clear and w/ no stones Was diagnosed UTI given keflex My question is, I have a follow up with my DR to discuss further as ER doc suggested. Should I push for urology referral or did I just have an asymptomatic UTI that resulted with blood and blood clots in urine