More Hard Conversations

Having garnered considerable praise for my handling of these cancer conversations (thank you) I would now like to go out on a limb and describe another, more recent, interaction for which I make no apologies, but which may very well evoke more criticism than praise.

I got a phone call last week from a guy in his 50s: "I'm peeing blood." I told him to come right over and sure enough, the specimen cup contained pure merlot instead of nice clear ale.

Here's the thing: gross hematuria (blood in the urine; lots of blood in the urine) although also caused by kidney stones or really bad bladder infections, has to be considered cancer until proven otherwise. Kidney cancer and bladder cancer, which can both present this way, are the "drop dead" diagnoses for gross hematuria and have to be ruled out definitively.

So in addition to a history, exam and urine culture, this guy was going to need a CT scan of his abdomen and pelvis, and a cystoscopy by a urologist. I was not going to stop until I was certain he didsn't have cancer. (Maybe someday I'll tell you about the last patient who peed blood whose initial CT was read as negative.)

To my way of thinking, I have to tell him this up front. Look at it this way: which is more alarming? Being told from the git go that I'm looking for cancer, or being sent all over kingdom come for rests and referrals and more tests without being told why? I trust my ability to tell the truth while remaining supportive, and so I opt for full disclosure.

I sat down with him (known him for over ten years) and his fiancee (whom I'd just met) and laid it out. It could be just a bad bladder infection (less likely in a male, though) or kidney stones (even though he didn't have any renal colic or kidney stone-type pain) but I was worried because cancer can cause that kind of blood in the urine, and we needed to rule it out.

He got a little teary but the fiancee was a tower of strength. I called the urology office and got him an appointment in less than a week, and pulled strings at CT to get him in the day after next (including getting a pre-cert all by myself; no staff that week.)

But here's what happened:

On exam, his temp was 100.1. He had no CVA tenderness and a benign abdominal exam, but a giant, non-tender prostate on rectal exam. I had actually documented it (huge; asymptomatic; normal PSA of 1.7) a few months back on a routine physical. He had to run to the bathroom four times during the visit, meaning he had what would be called "significant lower tract symptoms." The urine was filled with blood, to the naked eye as well as on dipstick and microscopic (meaning there was no way to tell if there were excess white cells with all those red ones, which would point to infection.)

I gave him generic trimethoprim-sulfa (cheap; great bacterial coverage and tissue penetration for both kidney and prostate; all infectious bases covered pretty well) and by the next day his fever was gone, the bleeding had stopped and he was feeling "100% better." His PSA was still less than 2 (low likelihood for prostate cancer) and his renal function and blood count were fine. The kicker was that his urine culture grew out a pan-sensitive E. Coli. Yesterday I got the CT report: no renal masses. I haven't yet heard from Urology, but I'm optimistic (1. That they did a cysto; 2. That it was normal; 3. That I will hear from them.) So the whole thing is looking more like a hemorrhagic cystitis with or without a superimposed prostatitis, probably all secondary to subclinical urinary retention from his enormous prostate, with no cancer at all.

Here's the question: Did I do the right thing by trotting out the C-word at the start?

It's a real one, and I don't know the answer yet. I will be talking to the patient in the next few days, and (assuming everything is fine) I shall ask him how he felt about it. I'll report back here, and we can all compare notes.

Whaddya think?