Rena and her husband were married one year, had settled in, and now planned to begin a family. They didn't want to wait much longer to start a family as they were both approaching 30. Two, maybe three children were agreed upon.
Rena's presenting complaint was burning when she emptied her bladder. She had had it only once before when she returned from her honeymoon (honeymoon cystitis).
I asked, "Aside from the burning, are you having any itching down there?"
"What about a discharge?"
"No. Nothing but the burning when I pee."
"Is your husband having any issues?"
"You mean like pain or redness?"
"Yes, anything. Any discomfort at all."
"No. He's not having anything. And if he did he'd be on his way out!"
"You mean like out temporarily, or permanently?"
"I mean like out so fast it'd make his head spin!"
"Okay. I'm going to prescribe an antibiotic but after taking it you need to return to the office for a follow-up urine since you have some microscopic blood in it. The blood is probably and usually the result of the infection. But we need to make sure it's not from something else too."
Two months later Rena returned with the complaint of burning on urination. I asked her why she didn't return for the repeat urine and she said her symptoms had resolved, she felt better, and didn't have time to come in. She was working two jobs, one as a realtor showing houses. Another urinalysis revealed white blood cells (infection cells), bacteria, and again the microscopic-appearing blood.
"Okay. You have another bladder infection. Here's an antibiotic. If this happens again I think you need a kidney xray to make sure you don't have any other problems other than the infection. But be sure and come back for a follow-up urinalysis."
"Well, I think I got this one because we've been having more sex."
"Okay. Then is your husband circumcised?"
"Uh, yes. Yes he is."
"Okay, but again, come back after you've finished the antibiotic for a follow-up urine and if it shows blood again we'll have to do the IVP."
"Okay, I will."
Three months later Rena returned with mild abdominal cramping. She thought it was due to her menstrual cramps as her periods had changed slightly. She didn't have any burning but said she felt her bladder area just above the pubic bone was tender and painful to press on it. She had no associated back pain. Another urine revealed the same results.
"Okay. Look, Rena, we definitely have to do an xray. You've had recurrent symptoms in the last few months. I'm going to order the IVP."
"Yeah, I understand, but I'd rather wait a bit since I'm really really busy. Plus, I'm the maid of honor for my brother's fiancee at their wedding and we're in the thick of it. I promise if it happens again that I'll go get the xray."
"Okay. You really need one now. But when you're ready just call and we'll order one right away."
Two months later, after a wedding, a Destin vacation, and a catering job had come and gone, Rena presented with mild weight loss, mild abdominal pain, low back pain, and a pink-colored urine that upon examination again revealed blood.
She finally consented to an IVP contrast dye kidney test which showed a one-inch shadow in her right kidney. A clarifying CT scan of the kidney revealed it to be a solid, irregular mass. A fine-needle biopsy revealed the mass to be a renal cell carcinoma (kidney cancer). At surgery, five lymph nodes were positive for metastatic cancer, so they removed her right kidney and multiple lymph nodes.
She felt better for six months, even on chemotherapy, after which she developed rapid fatigue, weight loss, and was found by her oncologist that the cancer had spread to her bones. She passed away almost two years to the day of her honeymoon. They never got to begin a family. She was 27.