I didn’t respond because I’m pretty sure someone as fabulous as you will be with us a long time. Keep me posted – I went on Kalshi and placed a bet on your condition – 90% are betting it’s an infection.

Thanks,

Gary Hunter

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I was the only one of four kids who didn’t pursue some sort of medical or scientific field.  My dad was a forensic pathologist, Mom an RN.  My brother recently retired from being an ER doc.  He was discouraged by American medicine and lived in New Zealand for 15 years where he saw patients in the ER.  Those folks are way more hearty than we are.  Anyway, this was his response:

Bob was probably treated with cephazolin IV (which is essentially IV keflex) and oral cephalexin (generic keflex).

In his age group and general history (lots I don’t know, like is he on anticoagulants? aspirin?), the most likely diagnosis is simply a ruptured vessel in the prostatic plexus. They become tangled and tortuous and under more pressure in old men. (Like me.) Most spontaneous nosebleeds are in the same population due to drier and thinner mucosa: blood vessels too thin out and become weaker. Renal or bladder stones (and bladder stones won’t show up) are the #2 cause. Infection is #3. Anything else is a distant #4. The CT is the appropriate test, along with various blood items and a urine culture. If the patient is not obstructed, there is no way in hell any urologist will give a damn and none anywhere will consult at night on almost any issue. I doubt a urologist came in even when I asked once per year in my career. (Testicular torsion, torn urethra with obstruction, really bad obstruction from clots or an infected stone in a diabetic or some such: that’s about it.)

450 mls of urine with 30 mls of blood looks like 100% blood. Only once or twice did I see significant blood loss from a urinary source and that was over days. Scary for sure.

Patient should have been set up for a follow up visit with a urologist in coming days and they would have likely scheduled cystography.  The shaking can easily come from the stress of pushing out an obstructing clot (also being faint, nauseated, dizzy). Rigors should certainly have been considered and infection carefully evaluated, though. Having no urinary obstruction is very important. I would have used a different Antibiotic these days, though cephazolin is not unreasonable.  And I would have called the guy or had someone call him the next day to make sure he was feeling Ok and we were getting follow-up organized as planned.

Sounds more reasonable now, doesn’t it?  Letting people know why things are done and where they are heading, as well as fail-safes are appropriate management.

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OK, hope that helps & that you’re doing well!

Galen Hudson