Symptoms

Blood in the Urine
PSA Elevation
Scrotal Mass
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Symptoms by Cancer

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Evaluation for Blood in the Urine (Gross or Microscopic Hematuria)

The standard evaluation or "work up" for hematuria includes an imaging study to evaluate the kidneys and ureters (the thin tubes that drain urine from the kidneys into to bladder), a visual examination of the bladder (cystoscopy) and a urine test such as a cytology (microscopic examination by specially-trained pathologists for cancer cells that can be seen using the Papanicolaou or "Pap-smear" stain. Generally all three tests are done, but the work up may be more limited if the risk of serious disease is very low and another explanation for the bleeding is likely.

Imaging Studies

Radiologists now have many ways to take pictures of the inside of our bodies. The most common is the familiar Xray, which may be improved by the use of contrast agents ("dyes" with iodine that block Xrays), "cuts" or "tomograms" that show one plane or 2 dimensional area of the body, or more commonly today computed axial tomography or CAT scans. Whenever Xray is used it is important that pregnancy is be excluded because Xrays can damage a developing fetus. If you are allergic to iodine or Xray contrast agents you should not receive iodinated contrast without special medication beforehand (antihistamine/steroid prep). Contrast can also cause kidney damage if you have diabetes or prior kidney disease. These issues should all be clarified before the procedure. An intravenous pyelogram or "IVP" is an Xray that uses contrast injected into a vein in your arm. The contrast is concentrated by the kidneys and excreted to provide Xray images of the kidneys, ureters and bladder. Better visualization of the kidney is obtained with the CAT Scan, though until recently the CAT scans did not show the ureters well. With 3D reconstruction techniques "hematuria CAT scans" now provide excellent visualization of the kidneys, ureters and bladder.

With the risk of allergic reactions and other side effects of IVP's and CAT scans, alternative imaging techniques are sometimes used. In patients with only microscopic blood in the urine and low risk for cancer (no family history of cancer, no exposure to cigarettes or other carcinogens, youth, female sex, etc.) studies suggest that a renal ultrasound is a satisfactory imaging study. This "sound wave" test is safe even for pregnant women and can be a useful screening procedure. If normal, more expensive and involved tests may not be necessary.

Magnetic Resonance Imaging (MRI) is a technique that like ultrasound does not require the use of Xrays or intravenous injection of iodinated contrast. Like CAT scans it may require that you be placed in a small, confined space. The images, depending on the technique and the equipment, can be excellent for the kidneys, ureters, and bladder. Like CAT scans, MRI has the advantage of showing other abdominal structures such as the liver as well as lymph nodes. If a tumor is present, the CAT scan or MRI can be useful in determining the stage (extent or spread) of the tumor.

Cystoscopy

Cystoscopy is the direct visual inspection of the bladder. While our imaging studies are good and getting better, they still are not good enough to show small bladder tumors or other bladder lesions that can cause blood in the urine. With cystoscopy a small optical device or "scope" is inserted through the urethra (the channel from the bladder) into the bladder. This is done with scopes that are much smaller than the normal channel (urethra) through which they pass, so pain does not generally occur. Cystoscopy takes only a few minutes and no preparation is required. We suggest that you drink a lot of water after the procedure to wash out any bacteria. The scope is sterile, but some irritation may occur and bacteria that are normally present just inside the urethra can be carried in with the scope. For that reason you may be given an antibiotic after the procedure.

Urine Cytology and Other Urine Tests

Urine cytology or "pap smear" is a microscopic examination of the urine stained with the Papanicolaou technique. A "pap smear" for cervical cancer takes cells directly from the cervix and provides no information about urinary tract cancer. It is best not to use the first voided urine in the morning for cytology because cells that have set over night are dying and may appear abnormal. No special preparation is required, but the urine should be preserved or sent to the laboratory promptly. The urine cytology is good for high grade bladder cancer and carcinoma in situ, but is commonly normal in the presence of low grade bladder cancer, ureteral cancer and kidney cancer. Therefore, cystoscopy is necessary in most cases even if the cytology is normal.

Other urine tests are being evaluated and several have been approved by the Food and Drug administration for the detection and follow up of bladder cancer. These include the BT Stat test, NMP22, and the UroVysion test. These tests have the advantage of being more sensitive than cytology, but, with the possible exception of the UroVysion test, have a higher incidence of "false positive" results than cytology.

Created: 3/15/2005

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