Hot Seat #145: 14yoM with bloody urine

Posted on: February 1, 2020, by :

HPI: 14 year old male presents to the ED from his PCPs office for evaluation of ongoing hematuria. He reports the symptoms have been present on and off for 2 weeks, but have never occurred in the past. He states his urine is bright red and does not clear with urination, but denies passing any clots. He reports intermittent dysuria, occasional urinary hesitancy, as well as intermittent dull abdominal pain. He was treated empirically for a UTI with Bactrim by his PCP when symptoms started, but symptoms persist and urine culture was negative. He denies increased urinary frequency, incontinence, fevers, vomiting, flank pain, penile pain or penile discharge. He has no history of easy bleeding or bruising. No history of UTIs or kidney stones. No history of clear trauma but he was a restrained passenger in a MVC last week. Reports being sexually active with one female partner, endorses intermittent condom usage, and denies history of STIs. No history of recent illness.

ROS: No fevers. No fatigue. Normal PO intake and UOP. Denies jaundice or petechiae. No recent illnesses including no sore throat. No SOB or chest pain. No vomiting or diarrhea. + Hematuria, dysuria, urinary hesitancy. No scrotal pain or penile discharge. No back pain. No headaches or dizziness.

PMHx: no past medical history, no UTIs, no kidney stones

PSHx: no past surgical history

FHx: no family history of bleeding disorders, kidney stones

Social History: lives at home with his mother, father, and 2 siblings

Physical Exam:

VS: T 36.7, HR 67, BP 116/75, SpO2 100%

    General:  Alert. Appropriate for age.  

    Skin:  Warm.  Dry.   No bruises. No petechiae.

    Head:  Normocephalic.  Atraumatic.  

    Neck:  Supple

    Eye:  Pupils are equal, round and reactive to light.  Extraocular movements are intact.  Normal conjunctiva.  No scleral icterus.    

    Ears, nose, mouth and throat:  Tympanic membranes clear.  Oral mucosa moist.  No pharyngeal erythema or exudate.  

    Cardiovascular:  Regular rate and rhythm.  No murmur.  Normal peripheral perfusion.  

    Respiratory:  Lungs are clear to auscultation.  Breath sounds are equal.  

    Gastrointestinal:  Soft.  Non distended.  Normal bowel sounds.  No organomegaly.  Bilateral suprapubic tenderness.  

    Genitourinary:  Normal genitalia for age.  No tenderness.  No discharge.  No lesions. No masses. Circumcised.  Testes descended bilateral. Tanner stage 5.  

    Back:  Right CVA tenderness

    Musculoskeletal:  Normal ROM. Moves all extremities. No edema of extremities.

    Neurological:  Alert.  No focal neurological deficit observed. 

    Lymphatics:  No lymphadenopathy

    Psychiatric:  Cooperative.  Appropriate mood & affect.  

Initial UA: Glucose neg, total protein 4+, bilirubin negative, pH 7.5, blood 3+ large, ketones small, nitrite negative, color amber, WBC 3+ large , specific gravity 1.020

Question 1:

Nephrology was consulted who recommended  repeat UA, urine culture, STD screening, CBC, CMP, ASO titers, C3/C4 levels, Hemoglobin Electrophoresis, and a renal/bladder ultrasound (RBUS). Repeat UA showed decreased blood, but hematuria persisted. CBC was reassuring with no anemia or leukocytosis. CMP showed normal kidney function, normal electrolytes, and normal LFTs. Initial RBUS showed normal kidneys, but was unable to visualize the bladder due to incomplete filling. Patient reports that suprapubic pain has resolved and he would like to go home.

Question 2:

Nephrology felt strongly that we repeat the RBUS to visualize the bladder, to which patient and his parents eventually agreed. Repeat RBUS showed findings concerning for ureterovesicular junction (UVJ) mass. Urology was consulted who arranged for expedited outpatient follow-up.

Question 3:

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Marci Fornari

Marci was born and raised right outside of NYC, but she is now a self-proclaimed Philadelphia (and Eagles fan) thanks to her husband. Over the past decade she has been making her way down the East Coast, and she is very excited to take advantage of all DC has to offer during her fellowship. Her academic interest include quality improvement, intimate partner violence screening, social determinants of health, as well as a goal to obtain an MPH. When she is not in the emergency department, you can find her on the beach, the ski slopes, at the dog park with her labradoodle, or at Orange Theory Fitness.

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