Posts Tagged ‘hematuria’

Blood In Urine: Reason For Worry?

March 25, 2017

Andrew Siegel MD  3/25/17

The medical term for blood in the urine is “hematuria.”  The most common type is seen only under a microscope and is referred to as “microscopic” hematuria. This is typically discovered at the time of a routine urine test during a health exam. When one can see blood in the urine it is referred to as “gross” hematuria, although I prefer “visible” hematuria. Visible hematuria may cause red urine if the bleeding is fresh or cola or tea-colored urine if the bleeding is old. Sometimes hematuria can be accompanied by blood clots, at times so severe that they clog up the outlet to the bladder causing the inability to urinate.  Sometimes hematuria is only evident by seeing bloodstains on one’s underwear or appearing on toilet tissue.

Image below is the urinary tract; note that blood in the urine can come from any part of this tract (Attribution of image: 2010, author Jordi March i Nogue)

256px-urinary_system-svg

ANATOMY QUIZ: Test your knowledge of urinary tract and adjacent anatomy by labeling structures 1-14 (answers at end of entry)

 

3 Misconceptions Concerning Hematuria

Misconception 1: If you have visible blood in the urine and it goes away, it can be ignored.

Truth: Even if it happens only once, it can be a sign of a serious underlying problem that needs to be determined.

Misconception 2: Microscopic hematuria can be ignored since you cannot see it.

Truth: Microscopic hematuria can be a sign of a serious underlying problem that needs to be evaluated, although it is less commonly associated with a serious problem than visible hematuria.

Misconception 3: Testing can always pinpoint the cause of the hematuria.

Truth: Sometimes the precise cause of the hematuria cannot be determined, despite appropriate testing. However, testing does result in excluding all of the serious underlying causes, meaning that whatever the cause, it is not of significance.

Like a nosebleed, hematuria can be a non-significant problem due to a ruptured blood vessel.  Alternatively, hematuria can be due to serious issues such as kidney or bladder cancers, the two most concerning causes of hematuria.  It is important to know that those who use or who have used tobacco (even if they ceased use many years ago) and have hematuria have a much higher risk of having bladder cancer than non-tobacco users.

Common causes of hematuria in men and women are benign prostate enlargement and urinary tract infections, respectively.  It can occur after vigorous exercise, particularly in those who have bladder stones or other structural abnormalities of the urinary tract. Although most hematuria is painless, when painful hematuria does occur it is often caused by a kidney stone, bladder stone or urinary tract infection. Many people use blood thinners for a variety of reasons. They do not cause hematuria, but if there is an underlying abnormality within the urinary tract, can provoke and perpetuate the bleeding. Hematuria can be a side effect occurring years after pelvic radiation for cancers of the bladder, prostate, uterus, etc.

How Hematuria Is Evaluated

Imaging Tests: A variety of tests can be used to image the urinary tract, including US (ultrasound), CT (computerized tomography) and MRI (magnetic resonance imaging). Retrograde studies involve the injection of contrast into the ureters (tubes that conduct urine from the kidneys to bladder) to image the upper urinary tracts.

Urine Cytology: A Pap smear of urinary tract cells to look for abnormal cells, obtained by providing a urine specimen.

Urine Culture: A lab test to see if a urinary infection is present.

Cystoscopy: A visual inspection of the bladder with a narrow, flexible instrument performed on a monitor with magnification.

Bottom Line: Do not ignore blood in urine, whether it is visible or microscopic. It may be “nothing” (not a sign of a serious illness) or may be “something” (a warning sign of a potentially life-threatening illness), so it is always worthwhile to be properly evaluated. If you experience hematuria, do not panic since the cause can usually be readily determined and treatment initiated; if the precise cause cannot be pinpointed, serious underlying causes can be excluded.

Wishing you the best of health,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”:  www.HealthDoc13.WordPress.com

Dr. Andrew Siegel is a practicing physician and urological surgeon board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  Dr. Siegel serves as Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community that is in such dire need of bridging.

Author of MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health http://www.MalePelvicFitness.com

Author of THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health  http://www.TheKegelFix.com

Answers to anatomy quiz:

  1. Urinary system
  2. Kidney
  3. Renal pelvis
  4. Ureter
  5. Urinary bladder
  6. Urethra (Left side with frontal section)
  7. Adrenal gland
  8. Renal artery and vein
  9. Inferior vena cava
  10. Abdominal aorta
  11. Common iliac artery and vein
  12. Liver
  13. Large intestine
  14. Pelvis

 

5 Things Every Woman Should Know About Her Man’s Pelvic Health

November 28, 2015

Andrew Siegel MD   11/28/15

4910841630_d096720d0d_o (1)

(Attribution: Pier-Luc Bergeron, A happy couple and a happy photographer; no changes made, https://www.flickr.com/photos/burgtender/4910841630)

Since this is Thanksgiving weekend and a broadly celebrated family holiday, I cannot think of a better time to blog about how wives/girlfriends/partners can help empower their men’s pelvic health.

  1. His Erections
  2. Prostate Cancer
  3. Bleeding
  4. Testes Lumps/Bumps
  5. Urinary Woes

 

Erectile Dysfunction: A “Canary in the Trousers”

If his erections are absent or lacking in rigidity or sustainability, it may just be the “tip of the iceberg,” indicative of more serious underlying medical problems. The quality of his erections can be a barometer of his cardiovascular health. Since penile arteries are tiny (diameter of 1-2 millimeters) and heart arteries larger (4 millimeters), it stands to reason that if vascular disease is affecting the penile arteries, it may affect the coronary arteries as well—if not now, then perhaps soon in the future. Since fatty plaque deposits in arteries compromise blood flow to smaller blood vessels before they do so to larger arteries, erectile dysfunction may be considered a genital “stress test.”

Bottom Line: If your man is not functioning well in the bedroom, think strongly about getting him checked for cardiovascular disease. His limp penis just may be the clue to an underlying more pervasive and serious problem.

Prostate Cancer

One in seven American men will develop prostate cancer in their lifetimes and most have no symptoms whatsoever, the diagnosis made via a biopsy because of an elevated or accelerated PSA (Prostate Specific Antigen) blood test and/or an abnormal rectal exam that reveals an asymmetry or lump. Similar to high blood pressure and glaucoma, prostate cancer causes no symptoms in its earliest phases and needs to be actively sought after.

With annual PSA testing, he can expect a small increase each year correlating with prostate growth. A PSA acceleration by more than a small increment is a “red flag.” The digital exam is simply the placement of a gloved, lubricated finger in the rectum to feel the size, contour and consistency of the prostate gland, seeking hardness, lumps or asymmetry that can be a clue to prostate cancer. It is not unlike the female  pelvic exam.

Bottom Line:  As breast cancer is actively screened for with physical examination and mammography, so prostate cancer should be screened for with PSA and digital rectal exam. In the event that prostate cancer is diagnosed, it is a treatable and curable cancer. Not all prostate cancers demand treatment as those with favorable features can be followed carefully, but for other men, treatment can be lifesaving.

Bleeding

Blood in the urine can be visible or only show up on dipstick or microscopic exam of the urine. Blood in the urine should also be thought of as a “red flag” that mandates an evaluation to rule out serious causes including cancers of the kidney and bladder. However, there are many causes of blood in the urine not indicative of a serious problem, including stones, urinary infections and prostate enlargement.

Blood in the semen is not uncommonly encountered in men and usually results from a benign inflammatory process that is usually self-limited, resolving within several weeks. It is rarely indicative of a serious underlying disorder, as frightening as it is to see blood in the ejaculate. Nonetheless, it should be checked out, particularly if it does not resolve.

Bottom Line: If blood is present when there should be none—including visible blood in the urine, blood stains on his undershorts or blood apparent under the microscope—it should not be ignored, but should be evaluated. If after having sex with your partner you notice a bloody vaginal discharge and you are not menstruating, consider that it might be his issue and make sure that he gets followed up.

Testes Lumps and Bumps

Most lumps and bumps of the testes are benign and not problematic. Although rare, testicular cancer is the most common solid malignancy in young men, with the greatest incidence being in the late 20s, striking men at the peak of life. The excellent news is that it is very treatable, especially so when picked up in its earliest stages, when it is commonly curable.

A testicular exam is a simple task that can be lifesaving. One of the great advantages of having his gonads located in such an accessible locale—conveniently “gift wrapped” in the scrotal satchel—is that it makes them so easy to examine. This is as opposed to your ovaries, which are internal and not amenable to ready inspection. This explains why early testes cancer diagnosis is a cinch as opposed to ovarian cancer, which most often presents at an advanced stage. In its earliest phases, testes cancer will cause a lump, irregularity, asymmetry, enlargement or heaviness of the testicle. It most often does not cause pain, so his absence of pain should not dissuade him from getting an abnormality looked into.

Your guy should be doing a careful exam of his testes every few weeks or so in the shower, with the warm and soapy conditions beneficial to an exam. If your man is a stoic kind of guy who is not likely to examine himself, consider taking matters into your own hands—literally: At a passionate moment, pursue a subtle, not-too-clinical exam under the guise of intimacy—it may just end up saving his life.

Bottom Line: Have the “cajones” to check his cajones. Because sperm production requires that his testes are kept cooler than core temperature, nature has conveniently designed mankind with his testicles dangling from his mid-section. There are no organs in the body—save your breasts—that are more external and easily accessible. If your man is not willing to do self-exams, at a moment of intimacy do a “stealth” exam under the guise of affection—it just might be lifesaving.

Urinary Woes

Most organs shrink with the aging process. However, his nose, ears, scrotum and prostate are the exceptions, enlarging as he ages. Unfortunately, the prostate is wrapped precariously around the urinary channel and as it enlarges it can constrict the flow of urine and can cause a host of symptoms. These include a weaker stream that hesitates to start, takes longer to empty, starts and stops and gives him the feeling that he has not emptied completely. He might notice that he urinates more often, gets up several times at night to empty his bladder and when he has to urinate it comes on with much greater urgency than it used to. He might be waking you up at night because of his frequent trips to the bathroom. Almost universal with aging is post-void dribbling, an annoying after-dribble.

Bottom Line: It is normal for him to experience some of these urinary symptoms as he ages. However, if he is getting up frequently at night, dribbling on the floor by the toilet, or has symptoms that annoy him and interfere with his quality of life, it is time to consider having him looked at by your friendly urologist to ensure that the symptoms are due to benign prostate enlargement and not other causes, to make sure that no harm has been done to the urinary tract and to offer treatment options.

Wishing you the best of health and a wonderful Thanksgiving weekend,

2014-04-23 20:16:29

http://www.AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in the in box of your email go to the following link and click on “email subscription”: www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback: www.MalePelvicFitness.com. In the works is The Kegel Fix: Recharging Female Pelvic, Sexual and Urinary Health.

Co-creator of Private Gym, a comprehensive, interactive, FDA-registered follow-along male pelvic floor muscle training program. Built upon the foundational work of Dr. Arnold Kegel, Private Gym empowers men to increase pelvic floor muscle strength, tone, power, and endurance: www.PrivateGym.com or Amazon.

Eyes Wide Open: Genital Mindfulness

May 9, 2015

Andrew Siegel MD 5/9/15

Pay careful attention to your body, including your genitals. Erectile function (or lack) is a barometer of your overall health and a bellwether for disease as well as an indicator of cardiovascular health.

Iris_-_right_eye_of_a_girl

Be Mindful

Observe your penis in both flaccid and erect states. Carefully watch and listen to your urinary stream. Keep an eye on  your urine and semen. It sounds strange, but by doing so you will gain insight into your general and pelvic health. Don’t forget to examine your testicles periodically when showering, feeling for lumps, bumps or asymmetry.

Skin Matters

Are there any rashes or skin lesions on the penis or scrotum? The genital skin—like the rest of our skin—can be subject to allergic responses, infections and cancers.

Power Tool No More?

Are you “limping” in the bedroom with less rigid and durable erections? This may be a sign of a problem with the cardiovascular system. The penile arteries are smaller than the coronary arteries of the heart and narrow before those of the heart have an opportunity to do so, so ED can be a predictor of a more generalized disease process involving other blood vessels.

Sex Drive Gone South?

Are you more interested in baseball than in sexual matters? If so, it may be time for a libido check and an evaluation of your testosterone level, as T is the “governor” of sex drive.

Erection Curved like a Banana?

Has your formerly straight erection gone “rogue”? Does it appear curved like a banana or is it angled like a periscope? Is there an area of narrowing that looks like a “waist” giving it an “hourglass” appearance? If so, you may have Peyronie’s disease, scarring of the sheath of the erectile cylinders of the penis causing a painful curvature.

Dribbling Instead of Shooting?

Did your previously powerful and intense ejaculation morph into a weak sputter of a small volume of semen with diminished intensity? If this is the case, you may have weakened pelvic floor muscles.

What’s That?

Is there a discharge from your urethra? If so, you might have a urethral infection/inflammation known as urethritis or other sexually transmitted infection. If you have not ejaculated in some time, it is possible that there will be a milky white discharge at the time of a bowel movement as the prostate is “milked” by the act of defecation.

Funky Colored Urine?

Urine color ranges from clear to amber, depending upon your state of hydration. When well hydrated, your urine will look clear or very pale yellow, like light American beer. When dehydrated, your urine becomes very concentrated, appearing dark amber, like a strong German beer.

Fresh bleeding in the urinary tract makes the urine appear bright red whereas old blood appears tea or cola-colored. In either case, blood in the urine is abnormal and should be investigated to ensure that the bleeding is not on the basis of a serious condition such as bladder or kidney cancer.

Excessive vitamin B intake can result in light orange urine. Overconsumption of beets, blackberries, and rhubarb can sometimes impart a red color to urine. Cloudy urine may be indicative of a urinary tract infection, but can also occur when one’s diet consists of foods high in phosphates.

When urine is occasionally foamy or sudsy, it is considered to be normal. When it occurs consistently, it can be a sign of protein in the urine, often indicative of kidney disease.

Funky Smelling Urine?

A sweet smell may indicate diabetes. A foul odor may be on the basis of a urinary infection or the intake of certain foods, e.g., asparagus. Vitamin intake can also cause the urine to have an unpleasant odor. Vitamins B and C are water soluble and therefore not stored in the body and any excess above what is necessary for the body’s use is excreted in the urine. Malodorous urine that has a fecal odor may indicate a bad urinary infection or possibly an abnormal connection between the colon and the bladder known as a fistula. This happens most commonly from diverticular disease of the colon and when it occurs, there is often air in the urine as well.

Does It Burn?

If urination is painful, it may indicate a urethral or urinary infection.

Can’t Put Out a Fire Anymore?

When you observe your flow, does it hesitate before it gets going? Is the stream weak and split into several streams or sprays like a spigot? Does it start and stop and seem to take forever to empty? When you have to go, do you have little warning and a tremendous desire to urinate? Are you leaking urine before you get to the toilet? Do you have an after-dribble? Does the sound of your urination that once was like the rapids of a powerful river now sound like a meek creek? If so, you may have plumbing issues on the basis of prostate enlargement, scar tissue in the urethra, or an overactive or underactive bladder.

Bloody Show?

Blood in the semen can literally scare the “daylights” out of you. However, the majority of men with “hematospermia” have a benign inflammation of the prostate that is not a serious problem, often as innocuous as a nosebleed.

Bottom Line: Scrutinize your genitals to discover much about your health.

Wishing you the best of health,

2014-04-23 20:16:29

AndrewSiegelMD.com

A new blog is posted every week. To receive the blogs in your email in box go to the following link and click on “email subscription”: 

www.HealthDoc13.WordPress.com

Author of Male Pelvic Fitness: Optimizing Sexual and Urinary Health: available in e-book (Amazon Kindle, Apple iBooks, Barnes & Noble Nook, Kobo) and paperback:          

http://www.MalePelvicFitness.com

Co-creator of Private Gym pelvic floor muscle training program for men:

http://www.PrivateGym.com 

The Private Gym is a comprehensive, interactive, follow-along exercise program that provides the resources to strengthen the pelvic floor muscles that are vital to sexual and urinary health. The program builds upon the foundational work of Dr. Arnold Kegel, who popularized exercises for women to increase pelvic muscle strength and tone. This FDA registered program is effective, safe and easy-to-use. The “Basic Training” program strengthens the pelvic floor muscles with a series of progressive “Kegel” exercises and the “Complete Program” provides maximal opportunity for gains through its patented resistance equipment.

What The Heck is Urology?

August 24, 2013

Andrew Siegel, MD  Blog #116

“Urology” (uro—urinary tract and logos—study of) is a medical specialty concerned with the study, diagnosis, and treatment of diseases of the urinary tract in females and of the genitourinary tract in males. The organs under the “domain” of urology include the adrenal glands, kidneys, the ureters (tubes connecting the kidneys to the urinary bladder), the urinary bladder and the urethra (the channel that conducts urine from the bladder to the outside).  The male reproductive organs include the testes (i.e., testicles), epididymis (structures above and behind the testicle where sperm mature and are stored), vas deferens (sperm duct), seminal vesicles (the structure that produces the bulk of semen), prostate gland and, of course, the scrotum and penis.  The reproductive and urinary tracts are closely connected, and disorders of one oftentimes affect the other…thus urologists are referred to as  “genitourinary” specialists. Urology involves both medical and surgical strategies to approach a variety of conditions.

Urology has always been on the cutting edge of surgical advancements (no pun intended) and urologists employ minimally invasive technologies including fiber-optic scopes to be able to view the entire inside aspect of the urinary tract, as well as ultrasound, lasers, laparoscopy and robotics.  There is a great deal of overlap in what urologists do with other medical and surgical disciplines, including nephrology (doctors who specialize in medical diseases of the kidney); oncology (cancer specialists); radiation oncologists (radiation cancer specialists); radiology (imaging); gynecology (female specialists); and endocrinology (hormone specialists).

Urologists are the male counterparts to gynecologists and the go-to physicians when it comes to expertise in male pelvic health.  Urologists, in addition to being physicians, are also surgeons who care for serious and potentially life-threatening illnesses, particularly cancers of the genital and urinary tracts.  In terms of new cancer cases per year in American men, prostate cancer is number one accounting for almost 30% of cases; bladder cancer is number four accounting for 6% of cases; and cancer of the kidney and renal pelvis (the inner part of the kidney that collects the urine) are number six accounting for 5% of cases.  Urologists are also the specialists who treat testicular cancer.  Urologists also treat women with kidney and bladder cancer, although the prevalence of these cancers is much less so than in males. 

Very common reasons for a referral to a urologist are the following: blood in the urine, whether it is visible or picked up on a urinalysis done as part of an annual physical; an elevated PSA (Prostate Specific Antigen) or an accelerated increase of PSA over time; prostate enlargement; irregularities of the prostate on examination; urinary difficulties ranging the gamut from urinary incontinence to the inability to urinate (urinary retention).

Urologists manage a variety of non-cancer issues. Kidney stones, which can be extraordinarily painful, keep us very busy, especially in the hot summer months when dehydration (a major risk factor) is more prevalent. Infections are a large part of our practice and can involve the bladder, kidneys, prostate, or the testicles and epididymis.  Urinary infections is one problem that is much more prevalent in women than in men.  Sexual dysfunction is a very prevalent condition that occupies much of the time of the urologist—under this category are problems of erectile dysfunction, problems of ejaculation, and testosterone issues. Urologists treat not only male infertility, but create male infertility when it is desired by performing voluntary male sterilization (vasectomy).   Urologists are responsible for caring for scrotal issues including testicular pain and swelling.   Many referrals are made to urologists for blood in the semen.

Training to become a urologist involves attending 4 years of medical school after college and 1–2 years of general surgery training followed by 4 years of urology residency. Thereafter, many urologists like myself pursue additional sub-specialty training in the form of a fellowship that can last anywhere from 1–3 years.  Urology board certification can be achieved if one graduates from an accredited residency and passes a written exam and an oral exam and has an appropriate log of cases that are reviewed by the board committee.  One must thereafter maintain board certification by participating in continuing medical education and passing a recertification exam every ten years.  Becoming board certified is the equivalent of a lawyer passing the bar exam.

In addition to obtaining board certification in general urology, there are 2 sub-specialties within the scope of urology in which sub-specialty board certification can be obtained—pediatric urology, which is the practice of urology limited to children and female pelvic medicine and reconstructive surgery (FPMRS), which involves female urinary incontinence, pelvic organ prolapse, and other female uro-gynecological issues.  The FPMRS boards were offered for the very first time in June 2013, and I am pleased to announce that I am now board certified in both general urology and FPMRS.  There are approximately 100 or so urologists in the entire country who are board certified in the urology subspecialty of FPMRS.

In terms of the demographics of urology, although urology is largely a male specialty, women have been entering the urological workforce with increasing frequency.  This is because female students now comprise approximately 50% of United States medical school population. There are 10,000 practicing urologists in the USA, of which about 500 are women. Urologists have a median age of 53, so we are not a particularly young specialty. The aging population will demand more urological health services and the Affordable Care Act will result in the dramatic expansion of the number of American citizens with health insurance. These factors combined with the aging of the urological workforce and the contraction due to retirement, all in the face of growing demands, does not augur well for a balance of supply and demand in the forthcoming years.  Hopefully there will be enough of us to provide urological care to those in the population that need it.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in Kindle edition

Author of: Male Pelvic Fitness: Optimizing Sexual and Urinary Health, in press and available in e-book and paperback formats in the Autumn 2013.

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Liquid Gold

February 23, 2013

Liquid Gold

Andrew Siegel, MD  Blog # 95

 

Urine is as valuable as gold is—at least when it comes to its potential for revealing our underlying health or infirmity.  Our kidneys work 24/7/365 filtering and removing from our bloodstream toxic wastes.  These include nitrogen-rich soluble products generated from cellular metabolism, numerous other organic and inorganic chemicals, salts and metabolites, as well as excessive water.  Urine—the end product appearing in our bladders—can provide amazing insight into our overall health.

With every pulsation of our heart, arterial blood flows into the kidney via the renal arteries; after the blood is filtered, the cleansed blood is returned via the renal veins.  In essence, the artery brings “dirty” blood to the kidneys for filtering, with the renal veins providing transport back of cleansed blood. Urine is a sterile by-product of this filtering process.  For this reason, when operating on the urinary tract (for example when the bladder is opened and urine enters the abdominal cavity), it is of no concern from an infectious point of view.

Using a simple and inexpensive dipstick, in a matter of moments, diabetes, kidney disease, urinary tract infection and the presence of blood in the urine can be diagnosed.  Although there are many benign causes of blood in the urine, the worrisome possibilities are kidney and bladder cancer.  The dipstick also reveals specific gravity, a test that can indicate dehydration, over-hydration, and other potential health issues. Not only can the dipstick disclose the presence of diabetes mellitus (sugar diabetes), but it can also reveal a condition known as diabetes insipidus, in which the kidneys lose their ability to concentrate urine. As a result, massive amounts of dilute urine are produced, which can have dire consequences.  Urine testing can also reveal substance and performance-enhancing drug abuse. Who knew that a waste product could be so revealing?  Of all the waste products that humans produce, urine uniquely provides the best “tell” regarding our health.

Urine odor can provide information as well. A sweet smell is consistent with diabetes mellitus; a foul odor may indicate a urinary infection or the intake of certain foods such as asparagus.  Vitamin intake can also cause the urine to have an unpleasant odor. Vitamins B and C are water soluble and therefore not stored in the body.  Any excess above what is necessary for the body’s use is immediately excreted in the urine.  Malodorous urine that has a feculent scent may indicate an abnormal connection between the colon and the bladder that is known as a colo-vesical fistula. This happens most commonly on the basis of diverticular disease of the colon.  When it occurs, there is often air in the urine, designated by the term pneumaturia.

Color is a “tell” with respect to hydration status.  When well hydrated, our urine will look clear or very pale yellow, like a light American beer.  When dehydrated, our urine becomes very concentrated, appearing dark amber, like a strong German beer.  Excessive B vitamins can result in light orange urine. Red urine is most often blood in the urine, which may indicate a potentially serious underlying condition, although overconsumption of beets, blackberries, and rhubarb may sometimes impart a red color to urine.  “Iced tea” or “cola” colored urine is often indicative of old blood, as opposed to the bright red color of urine indicative of fresh and active bleeding. Dark brown urine may indicate jaundice.  Pyridium, prescribed for the discomfort of urinary infections, turns the urine a neon orange color.  Other urinary analgesics that contain methylene blue can turn the urine blue or green.  Cloudy urine may be indicative of a urinary tract infection, but can also occur when phosphate salts crystallize in the urine on the basis of dietary intake of foods high in phophates.

When our urine is occasionally foamy or sudsy, it is considered to be normal. When it occurs consistently, it can be a sign of protein in the urine, indicative of kidney disease.

Bottom Line:  Urine is an invaluable waste product and offers many clues as to our overall health or presence of illness.

 

What a dipstick can reveal:

specific gravity…status of our hydration

pH…acidity of urine

leukocytes…urinary infection

blood…many urological disorders including kidney and bladder cancer

nitrite…urinary infection

ketones…in the absence of carbohydrate intake, fat is used as fuel and ketones are by-products of fat metabolism; may also indicate a very serious condition known as diabetic ketoacidosis

bilirubin…a yellow pigment found in bile, a substance made by the liver; its presence may be indicative of jaundice

urobilinogen…a byproduct of bilirubin breakdown formed in the intestines by bacteria—when elevated may indicate: impaired liver function; hepatitis; cirrhosis; excessive breakdown of red blood cells—when low may indicate bile obstruction or failure of bile production

protein…kidney disease

glucose…diabetes

—————————————————————————————————————————————————————————————————————

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

Blog subscription: A new blog is posted every week.   On the lower right margin you can enter your email address to subscribe to the blog and receive notifications of new posts in your inbox.  Please avail yourself of these educational materials and share them with your friends and family.

Bladder Cancer

February 2, 2013

Bladder Cancer

Andrew Siegel, MD  Blog #92

 

Bladder cancer is such a common public health problem that I thought it would be worthy of an educational blog.  Few people realize that its occurrence is more highly linked to tobacco than is lung cancer.

In the USA, the incidence of bladder cancer has increased greatly over the last few decades, with more than 60,000 new cases diagnosed each year.  It is the fourth most common cancer in men and the eighth in women. With the exception of skin cancers, bladder cancers are the most frequently recurring cancer, with up to 70% of patients experiencing recurrence.  The occurrence of bladder cancer increases with age and is three times more common in men than women.  80% of newly diagnosed individuals are 60 years of age or older.  At present, about 20% of patients die each year, but when the disease is diagnosed and treated in the early stages, the chances of survival are excellent, highlighting the importance of a timely and accurate diagnosis.  More than 90% of newly diagnosed bladder cancers are urothelial cell carcinomas  (cancers originating from the unique lining of the urinary tract).

The majority of patients with newly diagnosed bladder cancer have superficial cancer that involves the very inner layers of the bladder wall.  About 20% have invasive disease that involves the deeper layers of the bladder wall.  The remaining 5% present with metastatic disease, defined as spread beyond the confines of the bladder.

The highest prevalence of bladder cancer is in industrialized nations.  Cancer-causing agents (carcinogens) are most often responsible for bladder cancer.   Bladder cancer is highly associated with tobacco smoking—even if one stopped smoking years ago, the risk is related to the quantity of tobacco smoked over the years.  The carcinogens that are present in tobacco are absorbed through the lungs into the bloodstream and are filtered through the kidneys directly into the bladder, where their prolonged contact time with the lining of the bladder leads to cancerous changes.   Certain occupations are at higher risk for bladder cancer because of exposure to chemicals—these include: hairdressers, painters, machinists, printers, and those who work with dyes, textiles, rubber, leather, and petrochemicals.

Bladder cancer most commonly manifests with blood in the urine, either visible or microscopic (seen only under microscopic magnification).  It may also cause irritative lower urinary tract symptoms including urgency, frequency, discomfort with urinating, and urinary leakage.

The evaluation for blood in the urine includes imaging, cytology, and cystoscopy.  Imaging tests are means of visualizing the anatomy of the urinary tract, typically through ultrasound, computerized tomography (CT), or magnetic resonance imaging (MRI).  Cytology is a microscopic inspection of a urine sample by a pathologist for the presence of abnormal or cancerous cells that slough off the lining of the bladder, similar to a Pap smear done to screen for cervical cancer.  Cystoscopy is a visual inspection of the entire lower urinary tract (bladder and urethra) using a tiny, flexible, lighted instrument attached to a camera and monitor.

When a bladder tumor is identified on cystoscopy, attention is directed to the number of tumors present, their size, location within the bladder, and physical appearance.  A papillary appearance consists of fronds (finger-like projections floating in the bladder) with a narrow attachment to the bladder lining versus a sessile appearance, in which the tumor appears solid and is widely attached to the bladder lining.

Once a bladder tumor is recognized, it needs to be removed and sent for pathological evaluation.  This is performed under general or spinal anesthesia via cystoscopy, using an electric loop which is used to remove the area of concern as well as cauterize (use electricity to coagulate tissue) the underlying and adjacent tissue, both to stop bleeding and further destroy tumor cells.

The biopsed tissue is carefully examined by a pathologist, who will provide valuable information regarding malignancy vs. benignity, the type of tumor, depth of tumor, and grade of tumor.   Again, the vast majority of bladder tumors are urothelial cancers, referring to the cells that line the bladder.  A minority of bladder tumors are squamous cell cancers or adenocarcinomas.   Depth refers to the degree that the cancer is growing into the bladder wall.  Bladder cancers are broadly categorized into superficial and deep.  Superficial tumors are largely confined to the bladder lining and superficial layers and do not penetrate the muscle layer of the bladder, whereas deep tumors have “roots” that penetrate the muscular wall of the bladder.  Tumor grade refers to how much the microscopic appearance of the cancer deviates from the microscopic appearance of healthy bladder cells.  Low-grade cancers are similar in cellular appearance to normal bladder cells and generally behave in an indolent (slow) fashion versus high-grade cancers that can often behave aggressively.  Other factors of prognostic importance are the number of tumors present, the size of the tumors, and their physical characteristics.

In general, the best prognosis is for a solitary, small, superficial, low-grade papillary tumor and the worst prognosis is for multi-focal (originating from many different areas of the bladder), large, invasive (deep), sessile, high-grade tumors.

The biopsy information will enable the staging of the bladder cancer, a means of classifying the cancer.  It is extraordinarily unlikely for a superficial cancer to cause lymph node or distant spread, these events occurring with much greater likelihood with more deeply invasive cancers.

Staging of bladder cancer is as follows:

  • Ta: Superficial cancer is found only in polyps (papillary) on the surface of the inner lining of the bladder.
  • Tis: Carcinoma-in-situ. Tumor is found only in flat lesions on the surface of the inner lining of the bladder.
  • T1: Tumor is found in the connective tissue below the lining of the bladder but has not spread to the bladder muscle.
  • T2: Tumor has spread to the muscle layer deep to the lining of the bladder.
  • T3a: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer as identified under microscopic examination.
  • T3b: Tumor has spread through the muscular wall of the bladder into the fatty tissue layer and is capable of being identified without a microscope.
  • T4: Tumor has spread to the prostate in men and to the uterus or vagina in women, or to the pelvic or abdominal wall in either gender.

Superficial cancers are usually managed with cystoscopy, with regular “surveillance” due to the high predilection for recurrence.  It is imperative to have frequent check-ups (every 3 months for the first year after initial diagnosis), consisting of periodic urinalysis, urine cytology, imaging, and cystoscopy.  If surveillance does not demonstrate any recurrences, the interval between follow up can gradually be increased (to every 6 months in the 2nd year; if there are no recurrences, to an annual check-up).  If a recurrence is found, treatment must be repeated and the surveillance frequency then starts anew with the every 3-month cycle.

To help prevent recurrence, under certain circumstances it is beneficial to use a medication that is instilled in the bladder on a weekly basis—this is especially useful when many tumors are present, in the presence of a high-grade tumor, or cancers that have recurred.   It is particularly useful for carcinoma-in-situ (CIS), a variant of bladder cancer that is very superficial, flat, yet of a high-grade pathological nature.  The medication of choice is tuberculosis vaccine—BCG (bacillus Calmette Guerin), which is a live, attenuated (weakened) form of tuberculosis bacteria!

Muscle-invasive cancers most often need to be treated with a major surgical procedure involving either partial or complete removal of the urinary bladder.  In the circumstance that the entire bladder needs to be removed, the ureters (tubes that conduct the urine from the kidneys to the bladder) need to be diverted to a piece of intestine that is either attached to the skin to a collection bag (ileal conduit) or attached to the urethra (neo-bladder or “reconstructed” bladder).  At times, in lieu of surgery, chemo-radiation can be utilized (a combination of radiation therapy provided by the radiation oncologist and chemotherapy provided by the medical oncologist).

Bladder cancer often behaves as two separate types of diseases—one that typically presents as multiple, superficial papillary tumors that have a tendency to recur but are not lethal (similar to many skin cancers), versus another, more deadly form characterized by high-grade, non-papillary, muscle-invasive tumors that have a tendency to metastasize.  Fortunately, the vast majority of bladder cancers are the superficial type.

Andrew Siegel, M.D.

Author of Promiscuous Eating: Understanding and Ending Our Self-Destructive Relationship with Food: www.promiscuouseating.com

Available on Amazon in paperback or Kindle edition

For an educational video on bladder cancer that I have done, please go to the following link: http://www.youtube.com/watch?v=WvEOcCzw2gQ

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