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References

  1. Graber ML. The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013;22:ii21-ii27.
  2. Isabel Healthcare. YouGov survey of medical misdiagnosis. 2005. http://www.isabelhealthcare.com/pdf/misdiagnosis.pdf Accessed July 29, 2016.
  3. Singh H, Thomas EJ, Wilson L, et al. Errors of diagnosis in pediatric practice: a multisite survey. Pediatrics. 2010;126:70-79.
  4. MacDonald O. Physician perspectives on preventing diagnostic errors. Quantia MD. 2011. https://www.quantiamd.com/q-qcp/QuantiaMD_PreventingDiagnosticErrors_Whitepaper_1.pdf Accessed July 29, 2016.
  5. Wallace E, Lowry J, Smith SM, Fahey T. The epidemiology of malpractice claims in primary care: a systematic review. BMJ Open. 2013;3:e002929.
  6. Konety B, Zappala SM, Parekh DJ, et al. The 4Kscore® test reduces prostate biopsy rates in community and academic urology practices. Rev Urol. 2015;17:231-240.
  7. Nielsen M, Qaseem A; High Value Care Task Force of the American College of Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016;164:488-497.
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  9. Hale N, Choi K, Lohri J. Primary care evaluation and treatment of men with lower urinary tract symptoms. J Am Osteopath Assoc. 2014;114:566-571. http://jaoa.org/article.aspx?articleid=2094959 Accessed August 4, 2016.
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Contributor Information

Alana M. Ryan, DO
Staff Physician
Division of Graduate Medical Education
Henry Ford Allegiance Health
Jackson, Michigan

Disclosure: Alana M. Ryan, DO, has disclosed no relevant financial relationships.

Matthew Rosenberg, MD
Physician
Mid-Michigan Health Centers
Jackson, Michigan

Disclosure: Matt T. Rosenberg, MD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Astellas Pharma Inc; Medtronic Inc; OPKO Health Inc.; Tolmar Inc
Serve(d) as a speaker or member of a speakers bureau for: Astellas Pharma, Inc; Medtronic Inc.

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Diagnostic Error in Patients With Urologic Symptoms

Alana M. Ryan, DO; Matthew Rosenberg, MD  |  August 12, 2016

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Slide 1

Diagnostic errors are a major concern of both patients and physicians.[1] In a recent survey, more than one half of patients said they were very concerned about being diagnosed properly when they see a physician in an outpatient setting.[2] In addition, physicians consistently report encountering diagnostic errors. Moreover, compared with all safety concerns inherent to patient care, physicians worry that diagnostic errors are most likely to cause serious harm or death.[3,4] Malpractice claims bear these findings out: A failure to diagnose properly or a delay in diagnosis are the most common complaints in these claims.[5]

In this slideshow, Drs Ryan and Rosenberg describe diagnostic errors often encountered in patients with urologic symptoms. The following patient scenarios are not ranked in any order of importance, frequency, or potential harm.

Image from iStock

Slide 2

Not Another Biopsy, Please!

A 74-year-old African American man is referred to urology with a screening prostate-specific antigen (PSA) level of 7.8 ng/dL. He had seen a urologist in the past and has already had two prostate biopsies. In the electronic health record, a PSA level of 6.9 ng/dL from 1 year earlier was noted by his primary care physician; this physician referred the patient back to the same urologist for follow-up, where he was scheduled for a third biopsy. The patient presents for a second opinion, upset and tearful because he does not want to go through another biopsy.

Why is this a medical diagnostic error?

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Slide 3

Assessing Risk in Prostate Cancer

According to the US Preventive Services Task Force prostate cancer screening recommendations (currently undergoing revision), routine screening for prostate cancer is not recommended, owing to the large number of false-positive results. However, this can result in missing or delaying the diagnosis of prostate cancer in certain men.

Instead of performing a repeat biopsy, guidelines recommend obtaining biomarker testing to assess risk. Only when the patient's risk is high enough would a repeat biopsy be warranted. This patient is a prime candidate for the 4Kscore® test.[6] The four-kallikrein panel of biomarkers used in the 4Kscore test is based on more than a decade of research at Memorial Sloan Kettering Cancer Center and leading European institutions and is included as a standard of care in the 2015 National Comprehensive Cancer Network Prostate Cancer Early Detection Guidelines. Information from the 4Kscore test might have reduced the incidence of uncomfortable and invasive biopsies, and provided relevant patient risk information in a more timely manner.

For more discussion, a recent article detailed the ongoing debate about PSA screening.

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Slide 4

Testicular Pain and Mass

A 45-year-old white man presented to his primary care provider with pain and a mass in his right testicle. The patient had been treated 3 months earlier with antibiotics for presumed epididymitis. No further evaluation was performed at that time. The patient followed up as instructed after that antibiotic course concluded and his symptoms had resolved. Three months later, the patient returned with recurrence of pain (rated as 5 on a scale of 1 to 10) and a palpable mass in his right testicle. He denies any change in urination, fever, or systemic symptoms.

Why is this a medical diagnostic error?

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Slide 5

Ultrasound First

An ultrasound was performed which confirmed the presence of a mass. The eventual diagnosis was seminoma.

A complaint of pain with a testicular mass warrants ultrasound evaluation of the scrotum, a test that was not performed at the time of the patient's initial presentation. In this case, the mass probably caused inflammation and symptoms consistent with an infection. Initially, the antibiotics helped; however, the treatment delayed the diagnosis of the underlying cause of the patient's symptoms—a seminoma—which should have been discovered earlier in the process.

See this article for a more in-depth discussion of testicular seminoma.

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Slide 6

Probably Just a Stone

A 56-year-old white man presented to his primary care provider with left flank pain and frank hematuria. His medical history is significant for smoking as well as employment at a rubber tire factory. The patient was diagnosed empirically with probable left nephrolithiasis, sent home with nonsteroidal anti-inflammatory drugs (NSAIDs), and told to follow-up in 1 week.

The patient missed the follow-up appointment and returned 2 months later with a recurrence of his gross hematuria, although this time he denied pain. He stated that his previous treatment with NSAIDs relieved his pain temporarily, but the issue recurred. The patient was reassured of the diagnosis of nephrolithiasis, and was informed that further workup may be indicated if his symptoms did not resolve.

Why is this a medical diagnostic error?

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Slide 7

Gross Hematuria

The diagnosis of nephrolithiasis was made without laboratory confirmation. According to new guidelines from the American College of Physicians,[7] gross hematuria should trigger an immediate evaluation because it might signal urinary tract cancer. The workup should include cytology, radiologic imaging, and direct visualization of the bladder. Although this patient had risk factors to suspect cancer, any patient with presenting with gross hematuria warrants this comprehensive evaluation.

Follow this link for more in-depth discussion on evaluating patients with hematuria.

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Slide 8

Putting Faith in Antibiotics

A 62-year-old woman called on a Friday afternoon owing to recurrent urinary tract infection (UTI). She was experiencing urgency and frequency, and was desperate for medications to relieve her symptoms during an upcoming holiday weekend. A previous note in her chart states that antibiotics frequently resolve the condition, so an antibiotic prescription was sent to her pharmacy. The last time that urinalysis and culture had been obtained was more than 1 year ago.

Why is this a medical diagnostic error?

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Slide 9

Evaluating Patients With Suspected UTI

One cannot assume that this patient has a UTI without obtaining urinalysis and urine culture. In this case, a diagnosis of overactive bladder or interstitial cystitis must also be considered. The appropriate management involves having the patient come in so that a urine specimen can be obtained for urinalysis. Only with a urinalysis-confirmed infection should antibiotics be prescribed. Both overactive bladder and interstitial cystitis are common diagnoses, and symptoms can overlap with those of UTI. In this case, a more in-depth discussion with the patient would have revealed the presence of intermittent pelvic pain, leading to a higher suspicion of interstitial cystitis as the diagnosis.

Follow this link for more in-depth discussion of evaluation of patients with suspected interstitial cystitis.

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Slide 10

'I’d Rather Live With It'

A 63-year-old man presented with nocturia, urgency, frequency, and a mildly reduced urine stream. A prostate evaluation revealed a normal-sized, nontender gland. His PSA level was < 1.0 ng/dL. The patient was prescribed tamsulosin and told to follow up if his symptoms did not resolve. He returned 2 weeks later, reporting mild improvement in the strength of his urine stream; however, urgency, frequency, and nocturia persisted. He was told that his only option is urologic referral for possible transurethral resection of the prostate. The patient stated that he would rather live with the symptoms than pursue further intervention.

Why is this a medical diagnostic error?

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Slide 11

Evaluation of LUTS

This patient presented with lower urinary tract symptoms (LUTS). It is commonly believed that these symptoms (in a man) typically stem from the prostate. In fact, these symptoms can, and frequently do, stem from the bladder. This patient's symptoms were probably arising from overactive bladder, and the patient would have done well with an antimuscarinic or beta-3 agonist. The appropriate workup can readily be performed in the office of the primary care provider.[8] In addition to a detailed history, which should include a voiding diary, and physical exam, PSA testing is warranted in a man with LUTS and is not considered screening because it is a reasonable predictor of prostate volume.[9]

Follow this link for more in-depth discussion of assessment and management of overactive bladder.

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