Dr. Buck Holland - Try Second Opinion

By Dr. Buck Holland

TSO Expert Opinion provided by Dr. Buck HollandO

About Dr. Buck Holland

Speciality
Urology
Qualifications

MBBS, MS (General Surgery), M.Ch (Urology)

Area Of Expertise
  • Urological surgical procedures
  • Renal transplantation
  • Endoscopic urology procedures
Bio

Treat patients by reviewing and understanding their medical backgrounds and examining them to assess their current condition and health. Look at and employ ways of preventing, diagnosing and treating a range of kidney and urinary bladder diseases, Perform special procedures, such as bladder catheterization, renal procedures, removal of renal stones, and kidney surgical procedures to help diagnose and guide treatment of a variety of urological  conditions, Carry out a range of advanced interventional or surgical renal and bladder procedures. Prescribe medication to patients to help treat a range of urinary tract illnesses, Provide ongoing support and advice to patients under long-term care.

Education
  • MBBS in KIMS.
  • MS in KIMS.
  • M.Ch in Urology
Awards

Foundation Programme Certificate of Completion (FPCC), MRCS from the Royal College of Surgeons

Publications
  • Endoscopic removal of kidney stones in India J Urology Journal.
  • Presentation of hematuria in renal stones in European Urology Journal.

A case of a 55-year-old male with a three-month history of hematuria

Thank you for allowing me to participate in your care. As a reminder, my opinion given below is completely independent from the opinion given to you by your doctors.

Summary of Patient Medical History

To be thorough, I wanted to start by summarizing the information that I have obtained by reviewing your records.

You are a 55-year-old male with intermittent blood in your urine that has been ongoing for about three months and was not present before that. For the most part, it has been pain-free, but you have occasionally had some urinary urgency. You have not had any significant pain in your sides and have not otherwise had any difficulty with urination. You have not had any recent fevers. You have diabetes mellitus and high blood pressure that require regular medication, none of which is a blood thinner. You have never smoked. You have been to your doctors, and you have had a urine analysis, urine culture, blood work, and CT scan of your abdomen and pelvis. No obvious abnormalities have been found. You have been asked to monitor the bleeding rather than undergo any further investigation. Now you are interested in seeking a second opinion to see if there are any other options available.

Background Information

Before proceeding further, I would like to discuss various causes of blood in your urine. This information will help you better understand my thought process below. In medical terms, blood in the urine is called hematuria. Typically, urine should have no blood. When present, the blood can originate anywhere along the urinary tract, with examples including the kidneys, bladder, and prostate gland. Some specific problems can include inflammation in the kidneys, kidney stones, kidney tumors, inflammation in the bladder, bladder tumors, and various types of prostate disease.

The usual process to identify the cause of blood in the urine includes a urine analysis, urine culture to rule out urinary tract infection, blood work to check kidney function, and a CT scan or other imaging test to look at the urinary tract. At that point, if a cause has not been found, other tests can be considered. Some of these are more invasive and are therefore not done in all cases. It should also be mentioned that certain cases of blood in the urine do not have a clear cause, and as long as worrisome disease is ruled out, observation can be a reasonable course of action

Now, on to Your Questions

1. Can you tell why I have blood in the urine?

From the information provided so far, there is no obvious cause of blood in the urine. Your blood work indicates normal kidney function, and the absence of protein in the urine makes serious kidney disease that can lead to kidney failure unlikely. There has been no evidence of urinary tract infection. The CT scan of your abdomen and pelvis (which was done without and with intravenous contrast) did not show any kidney stones, kidney tumors, or obvious bladder problems.

2. What other tests do you think I need to do to get to the diagnosis?

Given your age, I would recommend a more formal evaluation of your bladder and prostate gland by a doctor called a urologist. Typically, the urologist will perform a direct exam of the bladder with a camera (called cystoscopy) to help rule out bladder inflammation and bladder tumors.

If the cystoscopy is unrevealing, the urologist might recommend seeing a medical kidney doctor (called a nephrologist) to look for less common kidney problems that might not have been picked up on any of the tests done so far. The nephrologist may order more blood tests and look at your urine under a microscope. A kidney biopsy may come up, but based on your normal kidney function and the repeated absence of protein in the urine, I do not think a kidney biopsy is warranted. Observation over time would be reasonable.

3. Are there any specific symptoms that I need to watch for in my day-to-day life?

This is an excellent question. The first step is to go through the evaluation above and see if any clear diagnosis is made. If not, then you should continue to monitor the frequency and amount of blood in your urine and keep an eye out for any new symptoms like side pain or weight loss. If any changes occur, it may be necessary to repeat certain tests or consider other less common tests. There would be no reason to limit activity unless a clear relationship between activity and blood in the urine became apparent.

4. Are there any immediate treatment options that I should pursue at this time?

Not as of this time. As above, the key is to complete appropriate testing.

5. Can you suggest any resources for me to look at?

Some trustworthy sites for patient information include the National Institutes of Health and the Mayo Clinic.

Summary of Recommendations

  • See a urologist for a formal exam of the prostate and bladder. This should include a direct exam of the bladder with a camera (cystoscopy).
  • If the visit to the urologist does not reveal any concerns, a visit to a nephrologist would be reasonable. However, a kidney biopsy does not seem necessary at this time.
  • If no answers are found, observation over time is reasonable. Initially, regular follow up with
    the urologist and nephrologist would make sense to make sure no new developments occur.

Thank you for allowing me and the Try Second Opinion team to be part of your care. I hope I was able to answer your questions and that you find these recommendations helpful. I would be happy to answer any further questions that you may have.

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