Urol Oncol-Semin Orig Investig.2013 Aug;31(6):909-913

Should the presence of a culture positive urinary tract infection exclude patients from rapid evaluation hematuria protocols?

Nikhil Vasdev, Andrew C Thorpe

Department of Urology, Freeman Hospital, Newcastle upon Tyne, UK

Abstract

Objective

Current rapid evaluation protocols for patients with hematuria tend to exclude those with urinary tract infection since this is assumed to be evidence of a benign treatable cause. The likelihood of a urinary tract cancer in such patients is, however, uncertain, and we have therefore analyzed a prospective hematuria clinic database to determine risk.

Patients and methods

A total of 1,740 patients were enrolled prospectively in this study at our unit’s one stop fast track hematuria clinic between April 2003 and March 2006. Evaluation of patients consisted of basic demographics, history and examination, urinalysis, urine culture, urine cytology, and serum creatinine. All patients then underwent a renal ultrasound, intravenous urogram, and cystoscopy.

Results

A total of 1,067 males and 673 females with a mean (range) age of 60.8 (16–96) years were included in the study. One hundred sixty-one patients had a positive mid-stream urine (MSU) on a specimen collected at the hematuria clinic. Amongst this group 20% (32) patients had a urologic malignancy diagnosed, of whom 12% (4) had metastatic disease at presentation. Only 1% (3) of patients had a urologic malignancy with a previous history of a treated urinary tract infection (UTI) and negative MSU at the clinic. The risk of urologic malignancy was 24% (303) in the remaining 1,249 patients with no history of a UTI prior to presentation and a negative MSU on a specimen collected at the one stop fast track hematuria clinic.

Conclusion

Despite selection bias inherent in this analysis, it appears that the presence of UTI does not decrease the likelihood of having a urologic malignancy diagnosed. Hence, there is no indication to delay prompt evaluation in patients with hematuria and a positive urine culture collected at the hematuria clinic.

Copyright © 2013 Elsevier Inc.

Keywords: Hematuria; Urinary tract infection; Urine culture; Urinary tract cancer

PMID: 21917488

 

Supplement

When a patient presents to his primary care doctor or as an emergency with either visible or non-visible haematuria, all patients are evaluated to exclude numerous causes of the haematuria including the presence of an active urinary tract infection (UTI) [1]. In the United Kingdom (UK) there are a set of guidelines to evaluate a patient with haematuria and similarly there are numerous guidelines present worldwide such as the American Urologic Association (AUA), American Cancer Society, or US Preventative Services Task Force to evaluate patients with haematuria [2].

When a patient has a confirmed UTI when being evaluated for haematuria, there is a propensity to link the UTI to be the primary and only cause of haematuria. In our paper we present an analysis to evaluate the likelihood of urinary malignant diagnosis in patients with UTI by analyzing data from a prospective one stop hematuria clinic (OSHC) database from our centre.

We present the data of 1740 patients who were evaluated with haematuria. In our paper we collected data including basic demographics, history and examination, serum creatinine, urinalysis for nitrites and leucocyte antigen, urine culture, and urine cytology. All patients underwent a renal ultrasound, intravenous urogram (IVU), and cystoscopy regardless of hematuria category. Although all patients in our department undergo a CT-IVU currently, this practice has been put in place since January 2009 [2].

Patients were classified into three groups. Patients in group 1 consisted of those patients who had a negative MSU diagnosed at primary care with a subsequent positive MSU at the OSHC. Patients in group 2 consisted of those with a positive MSU diagnosed in primary care, which was treated prior to evaluation at the OSHC. All patients in group 1 were confirmed to have a negative MSU on a specimen collected at the OSHC. Patients in group 3 consisted of those who have a negative MSU in primary care and at the OSHC. All definitions for haematuria and UTI were defined as per the 2009 European Urology Association (EUA) guidelines.

Data for a total of 1,067 men with mean (range) age of 61.7 (17–96) years in 673 women aged 59.9 (16–94) years attending the hematuria clinic were analyzed. A total of 28% (491) patients were diagnosed to have a urinary tract infection either on initial referral or during investigation at the one stop fast track hematuria clinic, i.e., groups 1 and 2. Group 1, 2, and 3 consisted of 161, 330, and 1,249 patients, respectively.

Four percent (7) of patients in group 1, 20% (67) of patients in group 2, and 10% (123) patients in group 3 were under the age of 40 years. Eighty-eight percent (1,543) of patients in the 3 groups were above the age of 40 on initial presentation to our units OSHC. The 3 groups were similar with regards to the age of presentation, gender distribution, and type of hematuria at presentation.

Twenty percent (32) of patients in group 1, 1% (3) of patients in group 2, and 24% (303) of patients in group 3 were diagnosed to have a urologic malignancy on investigation at OSHC. Twelve percent (4/32) of malignancies diagnosed in group 1 and 11% (36/303) of malignancies diagnosed in group 3 were metastatic at the time of initial investigation (Table 1).

 

Table 1. Details of the type of hematuria at presentation and details of tumor, stage, and grade of malignancies diagnosed

table 1

Bladder cancer was the commonest diagnosed urologic malignancy in all 3 groups. In group 1 (n = 32), 1 patient was diagnosed with carcinoma of penis, 2 with adenocarcinoma of prostate, 2 with renal cell carcinoma, 27 with transitional cell carcinoma of bladder, and 1 with squamous cell carcinoma of bladder. In group 2 (n = 3) all patients had non-muscle-invasive transitional cell carcinoma of bladder. In group 3 (n = 1,249), 10 patients were diagnosed with adenocarcinoma of prostate amongst whom 40% (n = 4) had metastatic disease at presentation. Twenty-one patients were diagnosed with renal cell carcinoma amongst whom 47% (n = 10) had metastatic disease at presentation. None of the 12 patients diagnosed with transitional cell carcinoma of the ureter/kidney had metastatic disease. A total of 268 patients were diagnosed with transitional cell carcinoma of bladder of whom 8% (n = 20) had metastatic disease at presentation. An additional 3 patients were diagnosed with squamous cell carcinoma of bladder amongst whom 66% (n = 2) had metastatic disease at presentation. In all groups, 4 patients were diagnosed with ovarian carcinoma and 1 patient had metastatic small cell carcinoma of lung. These patients have been excluded from our analysis as the tumors were non-urologic.

 

Our data confirms the following

  1. When a patient presents with haematuria especially when it is visible, a urological malignancy should be the top differential diagnosis
  2. Current protocols for the rapid evaluation of hematuria exclude those with a UTI since this is assumed to be evidence of a benign treatable cause.
  3. In our study, the current risk of urologic malignancy in patients with a positive MSU specimen collected at the one stop fast track hematuria clinic is 20%.
  4. The risk of urologic malignancy diagnosis is 24% of patients with a negative MSU on a specimen collected from the one stop fast track hematuria clinic with no previous history of a UTI on referral.
  5. Despite the selection bias inherent in this analysis, it appears that the presence of UTI at the time of investigation does not decrease the likelihood of urinary tract cancer diagnosis and, hence, there is no indication to delay prompt evaluation in patients with hematuria and culture positive urine.

 

In conclusion as mentioned in our publication, despite selection bias inherent in this analysis, it appears that the presence of UTI does not decrease the likelihood of urinary malignant diagnosis. However, in patients with an active UTI, it is prudent to treat the infection prior to investigation with intervention procedures such as a cystoscopy in order to prevent septic complications and morbidity. Hence, there is no indication to delay prompt evaluation in patients with hematuria and a positive urine culture collected at the hematuria clinic.

 

References

  1. Rodgers M, Nixon J, Hempel S, et al. Diagnostic tests and algo- rithms used in the investigation of hematuria: Systematic reviews and economic evaluation. Health Technol Assess 2006;10:iii–iv,xi–259.
  2. Vasdev N, Thorpe A. Should the presence of a culture positive urinary tract infection exclude patients from rapid evaluation hematuria protocols? Urol Oncol-Semin Orig Investig.2013 Aug;31(6):909-913

 

 

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Contact

Mr Nikhil Vasdev
FRCS (Urol)
Robotic Urological Fellow
(Royal College of Surgeons of England / British Association of Urological National Fellowship Programme)
Hertfordshire and South Bedfordshire Robotic Urological Cancer Centre
Department of Urology
Lister Hospital
Stevenage
UK
Email – nikhilvasdev@doctors.org.uk

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