Case Summary: 14yoM, otherwise healthy, presents with persistent hematuria despite empiric UTI treatment, ultimately found to have a bladder mass.

Here’s how you answered:

Denouement: Following discovery of mass on ultrasound, he was seen by urology, with plan of urgent cystoscopy to determine etiology of the mass. Biopsies were taken, and are currently pending.

Discussion: When this case was presented, two big points predominated. Firstly, (and apropos prior denouements), the importance of patient autonomy was discussed. Specifically, in a patient that is clinically stable and has a good follow-up plan (PCP and/or appropriate sub-specialists), home with close follow-up is very reasonable. In this case, after discussion the pros/cons of continued ED care vs home with follow-up, the patient and his parents decided to stay. Next, the group had a lively discussion about who and when we should empirically treat for STIs (noting that males are more likely to asymptomatic if infected). On one end of the spectrum, some advocated treating every adolescent, while others (invoking antibiotic stewardship) advocated ensuring good contact information and waiting for results to return. Many, however, remained in the middle utilizing shared decision making with the patient to determine treatment.

“You don’t have to take my word for it*…”: for those of you who want further information on pediatric hematuria, here is a review article discussing etiologies and proposing a diagnostic algorithm for the next patient you see with similar complaints (with either gross or microscopic hematuria).

*LeVar Burton, Reading Rainbow.