Q. An 86-year-old man presented with his first episode of urinary tract infection. He has no past medical history of note. Urine examination confirmed blood and protein, and E. coli was grown on urine culture. Which one of the following is the next step in management after treating him with antibiotics? A. Take no action B. Cystoscopy C. Retrograde pyelography D. Re-testing of urine with cytological examination after antibiotics E. Renal ultrasound scan
Quick answer: In an elderly man with his first UTI, the presence of haematuria (blood in urine) requires follow-up after treatment to exclude an underlying urological cause - particularly bladder cancer, which is more common in older males. The standard next step is to re-test the urine (urinalysis + urine cytology) after completing antibiotics to confirm the haematuria has resolved and to screen for malignant cells. If haematuria persists, further investigation (cystoscopy, imaging) follows.
The answer is D - Re-testing of urine with cytological examination after antibiotics.
Reasoning:
- Haematuria in an 86-year-old man is a red flag that must not be ignored, even when a UTI is confirmed.
- E. coli UTI can cause transient haematuria, but you cannot assume the infection is the sole cause without follow-up.
- The first step after treatment is to repeat urinalysis and urine cytology to check:
- Has the haematuria resolved? (if so, UTI was likely the cause)
- Are there malignant/atypical cells? (raising suspicion for urothelial cancer)
- If haematuria persists after antibiotics, or cytology is abnormal, the patient then proceeds to cystoscopy and upper tract imaging (USS, CT urogram).
- Cystoscopy immediately (B) without first re-testing would be premature - you first need to confirm whether haematuria persists post-treatment.
- Renal ultrasound (E) may eventually be needed but is not the immediate next step before confirming whether haematuria has cleared.
- Retrograde pyelography (C) is too invasive as an initial step.
- Taking no action (A) is inappropriate given his age and sex - bladder cancer is the most common urological cancer in elderly men and must be excluded.
This follows standard urology guidelines: any older male with haematuria (even in the context of UTI) needs urine cytology after treatment, and if haematuria persists, full urological work-up including cystoscopy.
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