This case takes place in Alaska and involves a fifty-five-year-old male patient who presented to his primary care physician complaining of six month history of hematuria and groin and hip pain. The patient also reported that he was experiencing occasional twitching sensations in the tip of his penis at the time. The physician suggested that the penile twitching sensation may be caused by sacral nerve root irritation. The physician did a work up of the patient for the hematuria and referred him to a urologist. The treating urologist performed a cystoscopy and ordered a CT scan. Both investigations were normal and the urologist did not believe further investigation was warranted and he discharged the patient. The patient continued to experience these symptoms and a second cystoscopy was performed some time later. This revealed an abnormal thickening consistent with a bladder tumor. A cystology report found atypical cells present suspicious for urothelial carcinoma. Subsequently, a transurethral resection of the bladder revealed a large, sessile, poorly differentiated appearing bladder tumor in the right lateral, toward posterior wall. The pathology report revealed high grade transitional cell carcinoma of the bladder with invasion into the muscle. The patient died due to the cancer shortly thereafter. It was alleged that by failing to order serial urine cytology testing despite months of persistent unexplained hematuria, gross and microscopic, the treating urologist did not deliver adequate care.
Question(s) For Expert Witness
- What is the standard of care when a patient presents with hematuria?
Expert Witness Response E-005320
The current recommendations state that testing for renal function level and cystoscopy & CT urography are the current standard if 3 red blood cells or more are in urine on urinalyisis with microscopy. If the workup is negative, follow up with at least one urinalysis and microscopy yearly for at least two years. If this proves positive repeat anatomic evaluation within three to five years or sooner if clinically indicated. These are the big drivers for more aggressive follow-up:
Risk Factors for Hematuria
•Age >40 years
•History of cigarette smoking
•History of chemical exposure (cyclophosphamide, benzenes, aromatic amines)
•History of pelvic radiation
•Irritative voiding symptoms (urgency, frequency, dysuria)
•Prior urologic disease or treatment
Potentially the most serious disorder in the patient with unexplained persistent hematuria is the presence of an undiagnosed carcinoma of the urinary tract. The combination of a negative CT urogram, negative cytology, and negative cystoscopy is usually sufficient to exclude malignancy in the urinary tract. However, the cause will subsequently become evident in some patients with careful follow-up. Had the treating physician followed these guidelines for this patient it is possible that his cancer would have been diagnosed sooner. Failure to continue follow up for a patient with persistent, unexplained hematuria is a departure from the standard of care.