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Hematuria and Abdominal Pain in a 60-Year-Old Woman

A 60-year-old woman presented to the emergency department (ED) complaining of red urine and gradual onset, intermittent abdominal pain over the past 2 years. The patient described her abdominal pain as a sharp, tearing sensation over her lower abdomen and suprapubic region involving both lower quadrants, with the pain on her left side exceeding that of the right. Activity and cough worsened the pain, while lying still often relieved the pain. She denied any nausea, vomiting , diarrhea, vaginal discharge, constipation, or bloody or melanic stools. She also denied dysuria but stated that she has had subjective fevers, urinary frequency and urgency, chills, and blood clots in her urine. The patient underwent bladder suspension surgery 6 months prior to this presentation, which resulted in more frequent episodes of abdominal pain and gross hematuria. The patient had presented multiple times to other EDs because of these symptoms. She either left without being seen or was diagnosed with a urinary tract infection (UTI), for which she was prescribed ciprofloxacin and acetaminophen with codeine (Tylenol #3), and was discharged without further work-up. Past Medical History The patient's past medical history included previously diagnosed osteoporosis, osteoarthritis, and diverticulo-sis via colonoscopy 20 years ago. Her current medications included 300 mg of acetaminophen with codeine (Tylenol #3) as needed for pain associated with her abdomen, 250 mg twice daily of naproxen for osteo-arthritis, 10 mg/d of alendronate sodium for osteo-porosis, and 0.625 mg/d of conjugated estrogen. She had no known drug allergies. In addition to the bladder suspension performed 6 months ago, the patient's past surgeries included a cholecystectomy in 1979 and a hysterectomy in 1975. Physical Examination The patient's vitals signs were as follows: pulse, 97 bpm; blood pressure, 144/62 mm Hg; oral temperature, 98.7°F (37.1°C); and respirations, 18 breaths/min. The patient was alert, lying still, and not in acute distress. There were no signs of rash, petechiae, or purpura on her skin. Examination of the patient's head, eyes, ear, nose, throat, and cardiovascular and respiratory systems was normal. Abdominal examination revealed well-healed scars from the aforementioned surgeries. Both bowel sounds and percussion were normal. There was no guarding or rebound, but the patient had tenderness with palpation in the suprapubic area. The results of a hemoccult test was negative. Genitourinary examination revealed normal genitalia and vagina without discharge or lesions. No masses were palpable on abdominal, rectal, or bi-manual examination. Extremity and back examinations …