NU-621 Herzing University – A 55-year-old woman presents to the office with bloody urine and dysuria of 12-hour duration. She was recently married and has never had

QUESTION

A 55-year-old woman presents to the office with bloody urine and dysuria of 12-hour duration. She was recently married and has never had similar symptoms. She denies chills and fever. On physical examination she is afebrile, has normal vital signs, and has mild tenderness in the midline above the pubis. Her urinalysis shows too many to count (TNTC) red blood cells.

1. What is the definition of bacteriuria?
2. What additional history do you need to make a diagnosis?
3. What diagnostic studies would you order and why?

ANSWER

Evaluation of Hematuria and Dysuria in a 55-Year-Old Woman: Diagnosis and Diagnostic Studies

Introduction

Hematuria, characterized by the presence of blood in the urine, is a concerning symptom that requires thorough evaluation. When accompanied by dysuria (pain or discomfort during urination), it can be indicative of a urinary tract infection (UTI) or other underlying conditions. In this case, we will explore the possible diagnosis and the necessary diagnostic studies required to reach a conclusive diagnosis.

Definition of Bacteriuria

Bacteriuria refers to the presence of bacteria in the urine. It is typically identified through a urinalysis, where the urine sample is examined for the presence of bacteria, white blood cells, red blood cells, and other relevant parameters (Crader, 2023). The presence of too many to count (TNTC) red blood cells in the urinalysis suggests a significant amount of blood in the urine.

Additional History for Diagnosis

To establish a definitive diagnosis, gathering additional history from the patient is crucial.

The following key questions would help guide the evaluation

 Past Medical History: Inquire about any known urinary tract disorders, kidney stones, or bladder infections, as these may predispose the patient to hematuria and dysuria.

Recent Sexual Activity: Given that the patient recently got married, it is essential to inquire about recent sexual activity. This information is relevant because sexual intercourse can introduce bacteria into the urinary tract, potentially leading to a UTI.

 Menstrual History: Assess the patient’s menstrual history and determine if the symptoms align with the timing of her menstrual cycle (“Hematuria (Blood in the Urine),” 2022). Hematuria related to menstruation or menstrual contamination can present with similar symptoms.

 Medications: Determine if the patient is taking any medications that may contribute to urinary symptoms or increase the risk of UTIs.

 Other Symptoms: Apart from bloody urine and dysuria, inquire about the presence of any other urinary symptoms such as urinary frequency, urgency, or lower abdominal pain.

Diagnostic Studies and Their Significance

 Urine Culture and Sensitivity (C&S): A urine C&S should be ordered to identify the causative organism, determine its sensitivity to antibiotics, and confirm the diagnosis of a UTI. This test is crucial for guiding appropriate antibiotic therapy.

 Urine Dipstick: A urine dipstick is a quick and cost-effective diagnostic tool that can provide preliminary information. It can detect the presence of leukocytes, nitrites (indicating the presence of certain bacteria), and red blood cells in the urine. While a positive dipstick result supports the diagnosis of a UTI, a negative result does not rule out infection.

 Imaging Studies: In some cases, imaging studies may be necessary to evaluate the urinary tract for structural abnormalities, kidney stones, or tumors. This may include a renal ultrasound, computed tomography (CT) scan, or intravenous pyelogram (IVP) (“Urinary Tract Imaging,” 2023). Imaging studies are particularly indicated when there are risk factors for urinary tract obstruction or when initial tests do not provide a clear diagnosis.

 Cystoscopy: Cystoscopy involves the insertion of a thin, flexible tube with a camera into the urethra and bladder. It allows direct visualization of the urinary tract and may be recommended if initial evaluations do not reveal the cause of hematuria or if other concerning findings arise.

Conclusion

 In the case of a 55-year-old woman presenting with bloody urine and dysuria, a comprehensive evaluation is necessary to determine the underlying cause. Gathering additional history, such as past medical history, recent sexual activity, and menstrual history, can help guide the diagnostic process. Key diagnostic studies include a urine culture and sensitivity, urine dipstick, and, if indicated, imaging studies or cystoscopy. Proper diagnostic evaluation is essential to establish an accurate diagnosis and provide appropriate treatment for the patient’s condition.

References

Crader, M. F. (2023, May 30). Bacteriuria. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK482276/ 

Hematuria (Blood in the Urine). (2022). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/urologic-diseases/hematuria-blood-urine 

Urinary Tract Imaging. (2023). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diagnostic-tests/urinary-tract-imaging