CASE 2 Painless Bloody Urination in a 60-Year Old Woman

A 60-year-old woman is referred to the emergency department (ED) because of a recent event of painless macroscopic hematuria. She reports having experienced several similar episodes during the past year, all of which resolved spontaneously. She regards these episodes as being of gynecologic origin because she is 5 years postmenopausal. She describes a general feeling of malaise in the days preceding the current episode, but she denies having any fever, dysuria, or increased frequency or urgency of urination. The patient also describes an unintentional weight loss of 11 lb (5 kg) during the past 2 years. The patient's previous medical history includes hypothyroidism that was treated medically with thyroxine, and her surgical history includes 2 treatments of dilatation and curettage (D&C) and a tonsillectomy. She has no known drug or food allergies, and she denies smoking, drug use, or alcohol consumption. She has no previous history of kidney stones or recurrent urinary tract infections.
On physical examination, the patient appears well. She has a temperature of 98.8°F (37.1°C), a pulse rate of 71 bpm, and a blood pressure of 150/86 mm Hg. The head and neck examination is normal. Lung auscultation reveals normal breath sounds bilaterally, without wheezing or crackles. Her heart sounds are regular, with a 2/6 systolic murmur maximally auscultated over the right second intercostal space. The abdomen is nondistended and nontender, no masses are palpated, and there are no signs of peritoneal irritation. No peripheral edema is noticed, peripheral pulses are palpated, and the neurologic examination is normal. A gynecologic evaluation that includes a speculum examination and transvaginal ultrasonography is performed, which reveals no pathologic findings.
A laboratory analysis, including a complete blood cell (CBC) count, coagulation studies, and a basic metabolic panel, shows a normal hemoglobin level, normal platelet count, and no coagulopathy. No electrolyte abnormalities are present. A urine dipstick test shows no signs of hematuria, and a urine culture is negative. Urine cytology is positive for malignant cells. Cystoscopy is performed, which demonstrates a normal urethra leading to a urinary bladder covered by normal mucosa, with no exophytic lesions and no active bleeding. A computed tomography (CT) examination of the abdomen and pelvis with intravenous contrast is obtained (see Figure 1).





FIGURE 1