Want to play "guess the diagnosis"? (I've been to the clinic)

In My Humble Opinion
1

You aren’t my doctor. I’ve been to the clinic. I’d enjoy having your help generating hypotheses.

I wake up to pee at 4:30 AM. Not unusual, especially since I stay well-hydrated. Went back to sleep.

I wake up to pee at 6:30 AM. Again, not unusual. My urine is bright red. I make arrangements to go to a medical walk-in clinic (not doc-in-a-box, but one of our health groups’ clinics). Between 6:45 and 8:00 AM, I urinate a lot, with increasing urgency, with more blood, including some clotting (or tissue). My urine is a uniform, beautiful cherry-red. I don’t have pain, just the “I’ve got to pee and I have no pee to pee at the moment” sensation.

At the clinic, the NP takes some history, summarized here:

  • Sudden onset of blood and urgency
  • Only one previous UTI in my life
  • No history of kidney stones
  • Never a smoker
  • No pain on urinating, just urgency
  • No flank or abdomen pain
  • No unusually heavy lifting
  • No new meds
  • I had a colonoscopy (without a urinary catheter) last week
  • No fever, oxygen is 100%, BP is 138/60, pulse is regular
  • No heart or lung issues noted, no kidney or abdominal pain on exam

She asked if I’d been nauseated and I said no more than usual with Tamoxifen and Ozempic, but that I had thrown up during colonoscopy prep the week before. Later, I realize that I had been very tired the last two days and lay down yesterday after my morning meds started making me queasy, but it was all mild enough that I didn’t remember it even in this context.

Urine dip showed

  • Bilirubin, 3+
  • Ketones, +1
  • Ph: 9.0
  • Glucose, negative
  • Specific gravity, 1.015
  • Blood, 3+
  • Protein, 3+
  • Urobilinogen, 2.0 mg/dl
  • Nitrite, positive
  • Leukocyte esterase, 3+

The NP said that since there was blood present, it wasn’t unusual for protein to be up. The leukocyte finding suggested a UTI to her and she prescribed an antibiotic, but given the amount of blood and the sudden onset, she couldn’t rule out a small kidney stone. She told me to talk with my PCP after the urine results come back from the lab, and that I might need imaging to check. I said I was aware that bladder cancer can present in the same way, and she said, yes, talk with my PCP. I was also to call my PCP if the blood and urgency didn’t abate or got worse by 48 hours out from the first antibiotic.

This, to me, is the interesting part: I went home, still had urgency and blood. I drank some water, ate a bagel, took my morning meds, and threw up without nausea. I drank some more water. The second time I urinated, there was less urgency and blood. With a few small urinations over the next half hour, the blood decreased, as did the urgency. I made no interventions except drinking some water (not a lot).

My lovely wife returned from the pharmacy and I took an antibiotic. 15 minutes later, I had straw-colored urine with no trace of blood, and haven’t had blood since. Urgency is back to normal.

Any ideas about what’s going on here and how to understand it? I’m intrigued and perplexed. Thanks!

2

More info would help me decide what differential diagnoses I’d like to consider/pursue. What’s your biological sex? If female, do you have an intact uterus/menstrual cycles/vaginal bleeding? What’s your age? Tobacco history?

I also hope a microscopic evaluation of the urine along with culture and sensitivity is being done, and they’re not just relying on a dipstick result.

3

For sake of discussion… assume past smoker instead of stated not one. Hematuria resolves. Still cystoscopy advised?

In kids a viral hemorrhagic cystitis or UTI would overwhelmingly lead the list. Adults are different.

4

For a single episode that resolves? Good question. “Unexplained” hematuria is still a very common “cause” of acute hematuria, along with stones, infections, and (if you’re the right age), cancer. Tho that last one is more likely to cause recurrent blood in the urine.

5

What’s your biological sex? Bio female.

Intact uterus Yes.

menstrual cycles not for 8 years. Menopausal.

vaginal bleeding I had a fibroid that caused trace bleeding removed with hysteroscopy/D&C 4 years ago, no bleeding since. The bleeding this morning was clearly urinary.

What’s your age? Early 60’s

Tobacco history? Perhaps 40 cigarettes as a young and stupid person.

I also hope a microscopic evaluation of the urine along with culture and sensitivity is being done, and they’re not just relying on a dipstick result. They’ve sent it to the lab for culture.

6

With that history in mind, the most common things that would cause an episode of transient visible blood in the urine would be “unexplained” (no cause found), UTI, kidney stone, exercise, trauma, and (less likely given your circumstances) endometriosis.

If blood in the urine becomes recurring/persistent, then the more likely diagnoses become things like SS/SA hemoglobinopathy, polycystic kidney disease, cancer of bladder or kidney, and intrinsic glomerular disease.

If your urine culture grows a single significant pathogen in large amounts, there’s your most likely answer. Given your positive Nitrite dip along with positive Leukocyte dip, that’s where the smart money is at the moment, even without you having symptoms. But it’s not a sure bet.

Good luck, hope you are over this now.

7

Thanks for your engagement. My hope is for a startling UTI or a tiny kidney stone. I’ll follow up here.

8

UTI would be at the top of my list for the differential diagnosis, followed by a kidney stone that’s reached the bladder. Did they do any blood work? That would be useful to narrow things down as well. Speaking from my experience as a patient rather than a physician, the severity of the hematuria isn’t always a reliable sign if the problem is a kidney stone. I’ve had urine that looks like water while having severe pain, and gross hematuria while otherwise feeling fine.

9

No blood work yet, but the urine has gone to the lab, and if anything stays weird, and maybe even if not, I’ll ask my PCP to order some tests when I see her in a couple of weeks.

10

A probably irrelevant anecdote since you already have a test that shows blood but … once I suddenly noticed that my urine was bright red. I freaked out and called my doctor and said there was blood in my urine. He said “You can see blood?! Come right in.” I came in and he took a sample, looked at it, and said “I don’t see any blood cells. Have you eaten any beets lately?” I had had beets for dinner the night before. Apparently beets can discolor your urine, although I’ve eaten them on other occasions without it happening.

11

A culture of the urine sample will help a lot as Dr. QtM said. A microscopic exam was/would be of limited value if there are a lot of intact red cells obscuring the view of bacteria or crystals. Acetic acid treatment of a sample would burst the red cells but would create a lot of debris that makes it harder to visualize bacteria. I hope you get a definitive answer soon.

12

OK, it’s probably not lupus. It was lupus once though, so you can never rule it out. Actually, if you want to take your mind off this watch some other show.

I do hope you are OK. Something like a small kidney stone or UTI are pretty good outcomes once you’re in your 60s.

13

They’re my preferred outcomes. I’d really prefer it not be cancer. It’s not beets. I’m on to that. Probably not endometriosis (my endometrium gets a look-see every couple of years), or sickle cell. Could be diabetes-related, but my kidney function is great and my blood glucose, while higher than I’d like, is low enough that I sometime have to fight to get good intervention.

14

Not that urine cytology is particularly sensitive for picking up abnormal cells (it’s most accurate for high-grade lesions), but hopefully such a microscopic exam was done anyway.

15

Tossed in the presentation is the fact that the OP is on tamoxifen, along with Ozempic.

Perhaps reasonable to assume treated breast cancer and obesity?

Ever been on cyclophosphamide (Cytoxan)? That contribute to hemorrhagic cystitis, I think even delayed. Plus while bladder seems an improbable location for metastasis I’d be hesitant to accept idiopathic if the culture is negative without some further investigation. But pediatrician so I may be off base!

Does obesity raise or lower anything on the differential?

16

Cancer and diabetes. I had Cytoxan 8 years ago.

17

So not likely Cytoxan hemorrhagic cystitis with that lag time but the history of that med does increase risk of bladder cancer, just like a history of smoking does. (I looked it up.)

Culture with significant growth will be reassuring that UTI is the cause, end, but if no growth then I’d personally sleep better crossing bladder cancer completely off the list, rather than waiting to see if it recurs.

18

Beet gives the urine a different color than blood does. The first time beets turned my urine red i was a kid, and i thought i was dying. My father (a doctor) was amused and assured me i was fine. I get bright magenta urine nearly every time i eat a lot of beets.

Susan, you mentioned a recent colonoscopy. Any chance that damaged the wall of the bladder, and the blood blister just popped or something?

(I am not a doctor, just thinking about what, other than an infection, stone, or cancer, might lead to bleeding inside the bladder or kidney.)

19

Yes, if the culture isn’t explanatory, I’ll ask for a bladder cancer assessment. I’m about due for kidney function testing as well.

I wonder if some fecal material entered the urethra. I also wonder about a bruise from the colonoscopy, but I don’t know if that’s even a possibility. Or, if it was a minute kidney stone plus a related infection. I’m still puzzled by the rapid onset of blood and urgency followed a couple of hours later by sudden decrease to little then no blood and no urgency before starting an antibiotic.

20

When i was pregnant with my second child, he often kicked the “gotta pee” nerve. (He also was in the way, and i had trouble emptying my bladder. I remember reading an ad for some prostate drug. It had a list of 10 symptoms, “if you have more than 7, ask your doctor about…” I had 9 of the 10 symptoms, and the tenth was something to do with your penis.)

Anyway, if you had something mechanical in just the wrong place, it could have given you that sense of urgency.

It seems weird to me that the urgency and bleeding exactly coincided. That’s why i was imagining a blister or swelling in the bladder that might have done both.