Misleading haematuria

It is easy to miss something when under pressure, recalls Dr Keith Barnard.

Chest X-ray revealed metastases (Photograph: SPL)
Chest X-ray revealed metastases (Photograph: SPL)

John was a pleasant young man aged 26 who I had known as a boy. The only entry on the computer under his history, apart from his vaccination record, was that he had an orchiopexy for cryptorchidism when he was two years old.

John was a batsman for a cricket club, and he complained that he was struggling when running. He was not short of breath at any other time, and just thought he was a bit unfit, but the previous weekend he had played a long innings and was exhausted at the end.

He had also noticed blood in his urine on one occasion. Closer questioning revealed no history of cough, recent illness or injury, and no other urinary symptoms. He had never smoked.

Unfortunately, I was running late and he was in a bit of a hurry. A quick examination of his abdomen revealed nothing of note, in particular there was no loin tenderness. His cardiovascular system was normal with a regular pulse of 52 beats per minute and normal heart sounds.

Listening to his chest, I thought there was perhaps some diminished air entry on the right, with perhaps an occasional sonorous rhonchus, but I was not sure.

He looked far too well to have pneumonic consolidation, and we decided that the best next step was a chest X-ray.

A surprising result
I had a shock when the result came back three days later. There were two masses in his right lung, and several small round shadows scattered through both lung fields. The appearances strongly suggested metastatic cancer.

I asked John back that same day, and performed the examination I should have done the first time. Cryptorchidism is a risk factor for testicular cancer, and I had overlooked this detail, not paying much attention as it was so long ago.

But reading about the condition I realised that even if an undescended testicle is brought down into the scrotum at an early stage, an increased risk remains.

I had not missed anything in his abdomen or any palpable lymphadenopathy, but there in his right testicle was a firm, non-tender mass.

Two days later, John was in hospital, where his seminoma was confirmed following ultrasound of the testicle and elevated tumour markers. These included an hCG of 7,250 mlU/ml (normal <3 mlU/ml) and an alpha-fetoprotein of 1,900 ng/ml (normal 0-20 ng/ml). No explanation was found for his episode of haematuria.

John had para-aortic lymph node involvement as well as his pulmonary secondaries, and although seminomas are radiosensitive as well as chemo-sensitive, he was treated with orchidectomy and carboplatin alone.

Thankfully he did well, and six months later his chest X-ray was clear, he was back to playing cricket without shortness of breath, and was on his follow-up programme.

  • Dr Barnard is a former GP from Fareham, Hampshire
Key Points
  • Other risk factors include mumps orchitis, genetic factors, HIV/AIDS and being Caucasian.
  • In men who have had testicular cancer, there is a 12 times risk of it developing in the other testicle.
  • Although a rare disease (2,100 cases per year in the UK) it is the commonest cancer in young men.
  • Survival rates even with metastatic disease are excellent.
  • Self-examination is the best method of achieving early diagnosis.

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