Onjuiste diagnoses in de urologie

Onjuiste diagnoses op het gebied van de urologie: een interessant (Engelstalig) artikel waarin 10 scenario’s duidelijk aangeven welke niet correcte diagnoses dreigen. Van ‘Not another biopsy please’ tot ‘putting faith in antibiotics’  waarin de regelmatig voorkomende blaasontsteking versus blaaskanker wordt behandeld.

Diagnostic Error in Patients With Urologic Symptoms

Diagnostic errors are a major concern of both patients and physicians. 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. 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. Malpractice claims bear these findings out: A failure to diagnose properly or a delay in diagnosis are the most common complaints in these claims.

In 10 scenarios, 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.

 

  1. 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.

2.      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 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.

3.      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.

4.      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.

5.      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.

6.      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.

7.      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.

8.      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.

9.‘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.

10. 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. 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

 

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