Blood in Urine

As a urologist, I would have thought that after all these years the message would have gotten out - blood in the urine (hematuria) is not normal and must be evaluated 100% of the time. Yet time and time again, I see patients and hear their stories about how they complained to their doctors about seeing blood in their urine. Were they whisked off to a urologist for further studies? Sadly, no. Many of them were told to "come back in several months and we'll see if the blood is still there" or "we'll throw antibiotics at you to see if the blood goes away, assuming it's from an urinary tract infection", the doctor says, "even though you don't have any signs or symptoms of infection."

Many patients do return, but some don't. Some have persistent blood in the urine and then are sent to the urologist. Others may not have blood at a follow up visit and are then incorrectly reassured that everything is fine. As we in the hematuria business know, blood in the urine just one time is reason enough for evaluation. Bad things can cause blood in the urine off and on, so just because the blood went away does not mean everything is fine. In fact, bad things may be quietly growing, giving out little warnings now and again.

The problem is not blood in the urine itself. Rather blood in the urine is a sign of something. Something that is not right somewhere within the urogenital tract. For men and women. It could be something as simple as a low-grade infection. It might be a bladder or kidney stone, bobbling around causing irritation of the lining and therefore blood. Or it may be an early warning sign of a kidney cancer, ureteral cancer or even a bladder cancer.

Whatever the cause, blood in the urine is not normal at any time and must be evaluated. Sure, if there is an infection, and there's no more blood after the infection is treated, then no further assessment is necessary. But that is because there was an obvious cause of blood, that when treated, resolved. However if there's blood in the urine and no evidence of infection, then a trip to the urologist is absolutely necessary. Nonnegotiable.

For some reason, most women have no problem going to see a doctor for evaluation of something that might not be right. Men, on the other hand, are a totally different animal. They will stall, drag their feet, whine, try to come up with far-fetched excuses for the blood, and use their best negotiating skills to weasel out of seeing the urologist. Unfortunately though, this can result in serious problems that can even be life-threatening. If a cancer is present, then oftentimes blood in the urine is usually an early warning sign. A warning sign that should not be ignored. If one were to wait months or years, as urologists see on occasion, then the cancer can go from a small easily treatable spot to become large and even spread to other organs or lymph nodes. Not a good thing.

The workup for hematuria is pretty basic and fairly quick. Not worth all the fuss. The urine is evaluated for signs of infection, and often a sample is sent off for DNA analysis to look for any genetic changes that may suggest cancer (NMP-22 or BTA stat are two examples). An x-ray, usually a CT scan, is performed to look at the kidneys, ureters and the surrounding organs.

Finally, and perhaps this is the reason that most men do their best to avoid going to a urologist, a good physical exam and a flexible cystoscopy are a must. With this, the urologist will pass a tiny, pencil thick, flexible fiber-optic scope up the urethra and into the bladder. The cystoscopy allows for direct vision of the lining of the bladder, prostate and urethra - common places for tumors to hide (and no, they can't be seen on CT scan). No other test or x-ray provides this information.

The good news is this is done with plenty of lubricating anesthetic jelly, and for the vast majority is only momentarily uncomfortable. It's not fun but it's really not that bad. I've performed thousands of cystoscopies and I always ask the patients if the procedure was as bad as they feared. Almost without exception I hear, "Actually it wasn't that bad. Why was I so worried?" I really don't know. Either way you get good news. Either nothing is found, or something is. Even if a cancer is found, usually they are small and at least you can deal with it and get it taken care of. Then you can move on.

So what if you or a loved one sees blood in the urine? Now you know to demand to see a urologist. Do not settle for anything less. You or your loved one's life may be at stake.

Related Topics: Prostate Health, Getting the Best Care

Technorati Tags: urology,hematuria,prostate,bladder,kidney stones

Cell Phones, PDAs and Less Time

So cell phones have become part of who we are. In medicine, it is how I can contact my patients anytime they have any questions or problems. Cell phones provide my patients a way of reaching me 24/7. I can call and see how a patient is doing while driving home, to exercise or to meet my wife for dinner. Just giving my patients my cell phone number offers them enough security to know that I am just a few numbers away. Without a doubt, cell phones have improved my ability to provide a higher level of care for my patients. Great. So now I am dependent on cell phones.

Along comes the PDA. First bulky and awkward. Then, after years of improvements and refinements, PDAs are now bulky and awkward. Hmmm. Something's wrong with this picture. Like most of us, the newest one is always going to be so much better than the last one. You know, the one that I finally mastered, only to have it fall into a toilet at LAX. Then of course, that model is no longer available and it is time to move to the next model, whether I want to or not.

Time to lower the bar. Relax, breathe slowly, the man with the little beard says.

And then some brilliant electronics wizards gets a bright idea: let's mix both a PDA and a cell phone into one. That way, Joe American can carry around and talk into something the size of a large flat potato. A new contraption that really is nothing like my favorite cell phone and also fulfills the need we must all have of carrying a bulky PDA with nowhere to put it. And to top it off, it isn't even a good phone or PDA. Wow. Count to ten. Breathe deep. Visualize a mountain lake. Lower the bar.

I finally get a great new phone, with a bit of PDA and surprise of all surprises, it still works at 1 1/2 years. Finally, after hours upon hours, I have come to understand all the subtle nuances and tricks that make it such a great tool. I now know what it must be like to finally achieve cell phone nirvana. I am at peace with my pocket friend. I drop my guard, finally content with what I have mastered.

And then it hits.

Suddenly without warning, two apparently independent events occur (or is that what They want me to believe?) - my computer, the host to all the information that I synch daily to my little friend, becomes a blabbering worthless machine. An electronic version of an Avian flu infected chicken. So it must be put down. I can handle that. My trusty phone is still here with me. But wait. Somehow, for no reason, I have just lost all my memory in my phone. All 600 entries? No problem, I'll just synch it to my...

...okay, let it pass. Think a happy thought. The babbling brook scene from the calendar. Lower the bar.

What's that you say, Mr. Computer Man? Even with the software disk, you are unable to get my new computer to synch with my tried and true phone. Repeat that? The phone is considered obsolete and so there is no longer any corporate support? I have to get a new phone and new system so I can continue as I have done for so long?

Okay, I can handle that. I have talked to all my friends, and now I know exactly what I want. The newest and bestest. But wait, the only way I can get this great new phone is to open a brand new account? But I have had an account with you for so long; surely you must know I am a good customer. Let me see if I understand this Ms. Cell Phone Lady, if I am a good customer for years, I can't get the phone I need. If I am a nobody, with no loyalty to the company and no past money gladly provided to contribute to your profits, not only can I get the phone I want, but I also get a rebate. Seems simple enough.

Drop those unrealistic expectations, Sheldon. Close your eyes and relax. Just lower the bar.

This takes me to the Myth of Sisyphus. That poor Greek guy sentenced to spend eternity pushing a stone up to the top of a hill, only to have it fall down the other side, and then to push it back up the hill again, and so on. Eternity is such along time. When Sis, as his good friends in eternity probably called him, finally realized that the darn stone was not ever going to stay at the top of the hill, he probably heard the same thing. Drop those unrealistic expectations, Sisyphus. It's just the way it is. The stone will never stay. Deal with it. Lower the bar.

Related Topics: Desk Rage, Cell Phones Raise Work-Home Stress

Cheating on my diet, or Cosmic TMJ Revenge

It was only 8 weeks into my exercise plan. I had decided, with the urging of my wife, that as my 50th birthday approached, this would be a good time to make that final assault on eliminating my intra-abdominal adipose, also called in technical terms, gut fat. It has been 8 weeks of sweating, jumping, running, controlling my portions (a nice way of saying eating less) and working on my "core." Last week, I had just performed one of those surgeries that makes you want to quit and open a hat store. The kind where you think, "hey, this will be a slam-dunk. I have done this thousands of times." As it turned out, it took more than 5 hours of struggling to perform a very difficult redo microsurgical vasectomy reversal. The patient did great, the surgery should work just fine. It was just that kind of day. I was exhausted, and was feeling very much in need of something special -- a treat to say "it's okay Sheldon, you did well, and now you are going to be rewarded..."

I looked around my office, and there sat the object of my desire - the one thing that I had been desperately craving during this "time to get healthy" program -- a green Dot. You know, those delicious, chewy candies that you used to get at the movie theaters until they started charging $25 a box. Not just any Dot. No, not a red, yellow or even orange. My favorite - a green Dot. So, deserving as I was for doing such a good job, I reached over and popped it into my mouth. So sweet, so "green" I thought. Yes, this is what I needed. I no longer felt deprived. Next, after the initial "just let it sit on your tongue phase," I proceeded to the next step in the formal Dot enjoyment process, thinking "so what if I have been working on my diet and fitness plan, and am trying so hard to avoid junk calories?" I began to slowly chew my Dot. And then it happened.

Sudden, excruciating pain. Could someone be stabbing a sharp red-hot poker into my left jaw? No, it was my one Achilles heel, but in my face - my TMJ deciding to tear and go into acute spasms. I could not chew the dot, nor could I even open my mouth. The severe pain was not going away. Was this all because I had decided to break my diet? Was there some evil power that was waiting for me to do this, just to inflict this pain and show me the error of my wandering ways? Could this just be a random event? Not likely. The truth has become clear to me. Though the pain continues now a week later, I have learned my lesson. Could I sneak another Dot at some point before I hit my target? Yes, I could. Would there be repercussions? Yes, no doubt. Somehow, someway I would regret eating another Dot. So I continue on my no-Dot and exercise diet. That is, until I turn 50 and hit my goal. Then, I will have earned permission to rejoin the world of those happy Dot loving people.

Related Topics: Get Healthy Without Really Trying, Keep Those 'New Year' Eat Better Resolutions

PSA Blood Tests

For years I have been talking about the relative inaccuracy of the PSA blood test. Yet I still believe it continues to save tens of thousands of lives each year. An elevated PSA saved the lives of many of my own patients more than 10 years ago - and they are alive and healthy today.

I still hear of situations where patients and even doctors misinterpret the PSA results. They don't seem to understand what the PSA is and what it isn't. For reasons that I think are totally human, doctors as a group seem to empower the PSA result with far more significance than it really deserves, or was ever intended to have. And just last week the perfect example occurred in my office. In fact, so good it begged to be described in this "mediblog," which sounds so much better than a "blogomed." Let me explain.

It all started with a follow-up visit with a patient. Let's call him Jim. He is a 72-year-old very healthy retired business executive. Very smart, very Internet savvy. Jim has had an elevated PSA for many years. Not dangerously high but enough to be of some concern. Yes, he has had several rounds of ultrasound-guided biopsies, all of which show no evidence of any cancer or even any precancerous PIN or atypia. Even with the risks for sampling error, the odds are good he does not have any large or significant cancer lurking in there. Still, we are following him with regular PSA levels and exams. Just to be sure.

Two weeks ago he had his PSA level drawn. Of interest, he had it drawn at two labs. Why, he isn't sure. He had the PSA drawn that our office ordered and then Jim went to his primary doctor who drew more blood and added on a PSA level, not knowing about the prior draw 30 minutes before. Here's the part that caused him some confusion. The results came back - one result at 7.2 and one at 8.4 - both from reputable labs, using state-of-the-art equipment. Both tests were drawn the same day, same patient, same hour. "How could this be?" he asked. "Is it going up that fast or is it dropping rapidly? What could I have done in 30 minutes that raised it or dropped it so much?"

"Aha", I said smiling like I knew a secret I was about to share. "Just as I expected." After his 15-second digital prostate exam was completed to confirm nothing had changed in 6 months, I explained what I have been saying for many years and have even written about in my book (yes, this is a plug, and a well-timed one at that). The PSA is a test of the prostate, not prostate cancer.

It is not an exact test, nor was it ever intended to be. The level can vary from day-to-day, lab-to-lab. It should be viewed as a ballpark test--information to be used in conjunction with the rest of the exam, history, and past results. Minor fluctuations are not only common, they are the norm. A PSA of 2.8 is the same as a PSA of 3.1 or 2.5. But despite my saying this over and over, year after year, people still look at their own levels as if they are precise results. They would see a change from 4.5 to 4.6 as a major sign of rapid and fatal cancer progression.

Now, though, I have a great example to demonstrate the fact that PSA is indeed a ballpark result. In fact, it is a nonspecific ballpark result so you can't even tell which ballpark it is in. Sure, it could represent a prostate cancer. It could also suggest prostate enlargement, infection, or recent injury such as a catheter placement or even a recent prostate biopsy (you should wait at least 8 to 12 weeks after a biopsy to recheck PSA). Sometimes it is just elevated.

If the PSA is elevated or goes up should you worry? Yes, a bit. If it is a concern, always ask to have it checked again in a few weeks. Then, if it is still up significantly or moving up, and your urine shows no sign of infection, it is time to see the urologist. No, you cannot wait 6 months. Call and make the appointment. It is a no-lose situation. If you have a cancer, then you usually catch it early and can decide what to do while you still have choices. Letting it grow just eliminates options, and shortens your lifespan. It's more likely that there will be no cancer and then you can quit worrying about the PSA level. And then, as most guys do, you can look for something else to stress about or ignore.

Related Topics: High PSA Level? Check it Again, Yearly Prostate Cancer Test May Save Lives