A Sexually Active 29-Year-Old Man With a Weak Urine Stream

Liana Meffert; Paul Gellhaus, MD


April 26, 2021


This patient's age (29 years), the absence of nocturia, and his uroflow study results reduce the likelihood of benign prostatic hyperplasia, which is more common in men older than 50 years.[2] He has a patent urethral meatus and no pain or history of trauma or surgery to the genital area; these findings tend to exclude a urethral stricture. Finally, the absence of fever, chills, gross hematuria, flank pain, and costovertebral angle tenderness makes a urinary tract infection less likely.

Bladder cancer is in the differential diagnosis for a young man with voiding symptoms; however, the average age at diagnosis is 73 years, and patients often have a significant smoking history, which was absent in this case.[3] This patient's most notable risk factor is his strong family history. Although gross or microscopic hematuria is the most common initial presentation of bladder cancer, irritative or obstructive voiding symptoms are not unusual.

Microhematuria often presents asymptomatically and requires a thorough workup. To qualify as microscopic hematuria, urine sediment must be examined by microscopy and demonstrate three or more RBCs in an HPF. This finding is the criterion standard for detecting hematuria because urine dipstick tests, while useful for screening, can be subject to false-positive results.

Microscopic hematuria is found in about 4%-5% of patients in routine clinical practice and has a broad differential diagnosis.[4,5] Infections of the lower urinary tract are among the most common causes of hematuria. Other urologic etiologies include urolithiasis, ureteral strictures, and benign prostatic hyperplasia. If the results of the workup prove unenlightening, idiopathic asymptomatic nonglomerular microhematuria may also be considered.

Glomerular hematuria must be differentiated from nonglomerular hematuria because glomerular hematuria makes it unlikely that the problem is urologic, and further evaluation of RBC morphology and renal function is required.[5] The presence of RBC casts is a specific but not sensitive finding for glomerular hematuria. The absence of RBC casts in this patient's urinalysis was used in conjunction with his clinical picture to rule out glomerular hematuria.

According to recent AUA guidelines for the workup of microhematuria, patients with the following characteristics are considered at low risk for cancer[6]:

  • Age < 50 years for women

  • Age < 40 years for men

  • No smoking history or a < 10 pack-year history

  • Hematuria of 3-10 RBCs per HPF

  • No additional risk factors

For low-risk patients, AUA guidelines specify that the options are to proceed with cystoscopy and renal ultrasonography or to repeat a microscopic urinalysis for hematuria in 6 months. Patients who have hematuria at their 6-month follow-up are reclassified as intermediate risk and are evaluated accordingly.[6] Although the patient in this case is young, his family history of bladder cancer is considered a risk factor, which puts him in the intermediate-risk category.


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