An Unusual Case of Flank Pain and Urinary Tract Infection in an Older Adult Male

Christy B. Krieg

Disclosures

Urol Nurs. 2018;38(4):177-183. 

In This Article

Abstract and Introduction

Abstract

A 76-year-old otherwise asymptomatic man presents to his primary care provider with febrile illness, suspected to be a urinary tract infection, and is referred to urology. He is ultimately found to have severe bladder outlet obstruction, a large bladder diverticulum, and a rare cancer. The urology care team must be alert to incidental findings and recognize the potential significance of unexplained findings.

Introduction

V.V., a 76-year-old Caucasian man, reported to his primary care provider (PCP) on March 27, 2017, with a three-day history of chills, fatigue, bilateral flank pain, and fevers spiking to 101.5 degrees Fahrenheit at night. His pain level was 8/10 at that visit, and physical exam was negative, with no costovertebral angle tenderness. His urinalysis (UA) in the office showed only trace hemoglobin. His blood pressure was 138/78, and his temperature was 98.7 degrees Fahrenheit. Suspecting a urinary tract infection with pyelonephritis (UTI), he was initiated empirically on sulfamethoxazole-trimethoprim (Bactrim DS) by mouth (PO) twice a day (BID) for 10 days. Urine culture from that visit was "mixed growth" and was not worked up further. He was asked to go to the lab the following day for blood tests.

V.V. was seen by the certified urologic nurse practitioner (CUNP) as a new patient on April 10, 2017, on referral by his PCP. The urologic NP obtained a full history and review of systems. He reported resolution of his fevers and improvement in his flank pain. He reported minimal, non-bothersome baseline voiding symptoms, including occasional dysuria, mild hesitancy with good flow, nocturia 0 to 1 times, daytime frequency every 2 to 3 hours, and no incontinence. He never had a UTI, urinary calculi, instrumentation, or catheter placement for urinary retention. He denied constipation or other chronic bowel issues, and there was no history of lower urinary tract symptoms or previous diagnosis of benign prostatic hyperplasia (BPH).

Past medical history: Chronic back pain. Hypertension. Hyper-lipidemia. Impaired fasting glucose. Osteoarthritis.

Past surgical history: Lumbar laminectomy L4-5, L5-S1 with fixation, 1999.

Allergies: No known medical allergies.

Current medications: Voltaren 75 mg daily. Oxycodone-acetaminophen 5–325, one PO q 6 hours for management of chronic back pain.

Social history: Never smoked; does not use alcohol or illicit drugs. Retired accountant, married, has three children.

Family history: Mother died of ovarian cancer at age 83. Father died of renal failure at age 87. Brother died of lung cancer.

The urology NP reviewed the labs drawn 2 days after presentation with UTI symptoms. Relevant findings include a creatinine of 1.8 with a glomerular filtration rate (GFR) of 36, compared to baseline 1.06, GFR 89 in July 2016 (normal reference range creatinine 0.8 to 1.2 ng/dL, GFR>60). All other testing, including complete blood count and blood culture, were within normal limits.

At the urology office visit on April 10, 2017, his urine was malodorous and cloudy with a pH of 5.0. It was nitrite negative, positive for 1+ hemoglobin, 3+ leukocytes, and 2+ protein. On microscopic examination, the urology NP noted the urine was packed with leukocytes and what appeared to be cocci. His post-void residual by ultrasound was 424 mL. The urology NP reviewed a computed tomography (CT) report of his pelvis from 2016 from an outside hospital that noted a large pelvic fluid collection thought to be a bladder diverticulum, lending support to a suspicion of long-standing urinary obstruction.

Concerned about his possible urosepsis and documented acute renal failure and urinary retention, the urology NP recommended placement of a Foley catheter, to which the patient reluctantly agreed. He was minimally symptomatic so the catheter seemed, to him, extreme. Ciprofloxacin was initiated at 500 mg PO BID, as was tamsulosin at 0.4 mg daily, with a planned voiding trial 4 days later with clinic cystoscopy at the same visit.

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