Hematuria, either gross or microscopic, is one of the more common problems presenting to Urologists for evaluation, accounting for up to 15 percent of hospital admissions to Urology services. It creates obvious concerns to patients; especially those with grossly bloody urine. There are varying degrees of urine, from one to three RBC/HPF to gross blood. The normal population will have some degree of microscopic hematuria and in fact up to three RBC/HPF is considered within normal limits. Any degree of true microscopic hematuria (>3 RBC/HPF) that persists on two or more examinations, or gross hematuria requires an evaluation for life threatening conditions.

Strenuous exercise, urinary tract instrumentation, and menstruation may induce hematuria, and therefore, evaluations for microscopic hematuria should be performed greater than 48 hours after exercise or instrumentation, or 2 weeks after menses to obtain the most accurate results. Urinalyses positive for blood on dipstick must be followed by a quantitative microscopic examination for red blood cells, as false positive results can occur in normal states as well as patients with myoglobinuria.

The differential diagnosis for hematuria is large, and includes conditions such as UTIs (most common), urolithiasis, renal or urothelial tumors, trauma, hemangiomas or arterio-venous malformations, glomerulonephritis (commonly in association with significant proteinuria), strictures, benign prostatic hyperplasia (BPH), or urethritis.

The work-up for hematuria, gross or microscopic, includes studies to diagnose the life threatening conditions that cause hematuria. History and physical examination will frequently elucidate the diagnosis, as in many other medical conditions. Urothelial or renal tumors are most common in the older population > 50 years old, especially in those with a history (past or present) of smoking or exposure to aniline dyes, benzene ring petroleum products, phenacetin-containing analgesics. Over 25 percent of men and women with gross hematuria will be found to have life threatening diseases, most commonly transitional cell carcinoma. Microscopic hematuria in women < 40 years of age have < 2 percent risk of a significant diagnosis. Urine culture must be obtained, even in asymptomatic patients, as infection is the most common cause of all hematuria.

Upper tract imaging is necessary to rule out renal or collecting system pathology, and can be accomplished in one of a number of ways. Intravenous urogram for patients without known contrast allergy and with normal renal function is the initial study of choice to image the kidneys and collecting system. Lesions, abnormalities, or incomplete studies will prompt further investigation. Ultrasound, MRI, or CT scan may be warranted. To further evaluate the ureters or renal pelvis, retrograde pyelogram is the study of choice and can be performed by a urologist at time of cystoscopy, another necessary procedure in the evaluation of hematuria. Filling defects or distortion of the ureters or pelvicalyceal system may prompt inspection with ureteroscopy, as stones or tumors are frequently encountered.

Urine cytologies may be of assistance in the initial evaluation to identify patients with high-grade transitional cell carcinoma or carcinoma-in-situ. Three voided samples can be obtained prior to the patient’s visit with the urologist, however, these must not be the first morning urine collected. Degenerated urothelial cells in the first morning urine may give false positive results initiating an unnecessary and invasive work up.

Annual urinalysis and cytologies should follow negative evaluations for 3 years. If no progression of hematuria or positive cytologies occur, the evaluation is finished. For recurrent or worsening hematuria, a complete repeat work up in indicated.

Phimosis is the condition in which the prepuce (foreskin) cannot be retracted to expose the glans penis. This condition is commonly associated with diabetes mellitus or recurrent episodes of balanitis, which lead to a circumferential scar or phimotic ring. As long as the patient is able to void, emergent treatment is unnecessary, and the patient can undergo elective circumcision. If the phimosis is due to massive edema, an ACE wrap can be sequentially applied from distal to proximal forcing the tissue fluid out of the prepuce. Alternatively, one can hold circumferential pressure on the penis for 5-10 minutes for the same effect. Occasionally, oral or parenteral sedation is necessary for the patient to allow manipulation of the phallus.

For a fixed preputial ring, a dorsal slit is necessary and recommended. Sterile technique should be observed. Using 1% or 2% xylocaine WITHOUT EPINEPHRINE, a wheal is raised in the dorsal midline of the inner and outer foreskin in the midline for 3-4 centimeters. The incision can always be extended, but avoid making the dorsal slit all the way to the corona. Place a straight clamp on the anesthetized skin and click it closed twice for approximately 5 minutes. This will cause the skin to appear blanched when the clamp is removed, and will reduce the amount of bleeding encountered. With scissors, cut the skin in the midline. The inner and outer preputial skin edge can be oversewn using an absorbable 3-0 or 4-0 chromic or monocryl suture on a non-cutting needle in a simple running pattern. Never leave a circumferential pressure dressing on the penis, as this could compromise the blood supply to the glans and cause tissue necrosis.

Paraphimosis is the inability to reduce a retracted foreskin back over the glans penis. This skin acts as a constricting ring and reduces blood flow to the distal phallus. This is an emergency. Patients are in severe pain, and frequently require narcotic analgesics to reduce the paraphimosis. Placing considerable pressure on the glans to push it back through the constricting tissue can do this. Surgical sponges may be necessary to obtain an adequate hold on the phallus and prepuce. Once reduced, a dorsal slit as described above can be performed.

Balanitis is inflammation of the glans penis. It is commonly encountered in men with poor genital hygiene, failing to retract the foreskin and clean the tissue beneath. In a military setting, the uncircumcised male living in the field is most at risk. Severe pain, redness and edema are common complaints. The treatment consists of the local application of antibiotic cream or ointment and diligent attention to personal hygiene. Warm soaks and non-steroidal anti-inflammatory medications will aid in reducing the discomfort and edema. Occasionally, oral antibiotics to cover common skin organisms are required to eradicate the condition. If the situation becomes chronic, elective circumcision in the absence of inflammation is the appropriate treatment.

Prostate cancer screening

The current recommendations by the American Urologic Association and the American College of Surgeons include an annual PSA blood test and digital rectal examination (DRE) for all men 50 years old and over. Screening should being at the age of 40 for those at high risk for prostate cancer at an early age. They include all African-American men, and all men with first degree relatives diagnosed with prostate cancer.

Patients should be referred for evaluation by a Urologist for any abnormal DRE (asymmetry or palpable nodule) regardless of PSA value, or a PSA greater than 2.5 ng/ml in all African-American men or Caucasian men less than 55 years old. For all other men, a PSA greater than 4.0 ng/ml is sufficient for referral.

Many parents request circumcision after the newborn period if, for medical, social or personal reasons, the circumcision was not performed at birth. Medical indications to perform circumcision at this age are few, however, the parents wishes should be honored. The child should be referred to a Urologist and the elective circumcision performed free hand after six months age when the risks of anesthesia are minimized.

UTI’s in children

Any child with a urinary tract infection must be referred to a pediatric urologist for evaluation. Up to 50 percent of these children will have vesicoureteral reflux which, if left untreated, can lead to renal scarring, hypertension, and renal failure. Once the acute infection is cleared with appropriate antibiotic treatment, the child must be placed on prophylactic antibiotics once a day to decrease the risk of a recurrent infection until the work-up is complete. A renal ultrasound should be performed to assess the size of the kidneys as well as the collecting system for dilatation. This study will not, however, rule in or rule out reflux. This must be done with a contrast or nuclear voiding cystourethrogram (VCUG). Bactrim or septra, amoxicillin, cefixime, or nitrofurantoin may be reasonable for prophylaxis. Do not use fluoroquinolones in children due to their association with premature closure of epiphyseal plates.

Any child being evaluated for a febrile illness should be assessed for a urinary tract infection with a urinalysis and culture. Children do not exhibit the classic irritative voiding symptoms as seen in adults with UTIs, but may complain of vague abdominal pain, anorexia, or malaise.

Enuresis

Enuresis, or nocturnal incontinence, is concerning to many parents as children advance to and past their toilet training years. Twelve percent of children ages 4 to 5 will wet the bed, with a resolution rate of 15 percent per year to the age of 19. Family history is generally predictive of what age a child will become dry at night. Encouraging fluid intake and urinating frequently during daytime, having the child void before going to bed, limiting the amount of fluid a child drinks several hours before bedtime, and bedwetting alarms all have shown success in helping these patients. Reassurance for the parents that this condition will resolve is important.

In the military recruit population, enuresis must be fully evaluated by a urologist. If the condition existed before enlistment (EPTE), the member may be administratively released from active service, as this is a disqualifying condition.