The other day I saw a middle-aged man who is a bit of a “character”. I suppose that is a polite way of saying that he doesn't always do what doctors ask or expect him to do. His story was a simple one, he had seen blood in his urine for several days. Yes it was bright red blood. No it didn't hurt when he passed it. No it hadn't happened before. And no, he hadn't been eating beetroot. So I gave him a bottle and asked him to nip into the toilet and produce a specimen. He came back with an empty bottle. “There was no blood in my urine” he explained, “so I didn't put any in the bottle.
I felt irritated and frustrated. What a silly man! And what cheek to disobey my clear instructions! However on reviewing the situation there seemed little doubt that he had been passing blood. So although it would have been reassuring to have found microscopic haematuria in his urine (a positive stick test even though the urine looked clear), I needed to refer him to the hospital. I did so, and today I received a letter from the hospital saying that he had been found to have a bladder cancer at cystoscopy.
Bladder and kidney cancers can bleed at an early stage and then not bleed again for a long time. So when a patient reports seeing blood in their urine it should be investigated straight away (unless there is a very good alternative explanation). In retrospect it was not a sensible thing to ask my patient to provide a urine sample, because if there had been no blood on stick testing I might have been tempted to tell him to go away and see if it happened again. I'm not saying that I would have done that, but I have a nagging worry that I might.
You should not order a test, even something as simple as a urinalysis, unless the result may alter your management. Even if a stick test had shown no blood in his urine he would still have needed to be referred. It was me who had been silly, and not my “character” of a patient.
Yesterday we had a little celebration at home which was a good reason to open a bottle of “bubbly”. My wife, who is a better cook than I will ever be a doctor, served up poussins. These are baby chickens that have had their guts and bones removed (apart from the leg bones) and are then stuffed, so that they look like a miniature roast chickens but can be eaten whole. To my surprise, I've been getting a little squeamish about eating poultry recently. Fish are OK, because they are fish and clearly nothing like us. Beef pork and lamb are OK, because the portions that are served up don't look like whole animals. But cooked poultry looks very animal like, with muscles and bones and ligaments. I confess that I felt a bit odd cutting into the soft white belly of my poussin - although it tasted delicious.
Matters were made worse today when I had to examine a baby that was just a few weeks old. Its soft white protuberant belly that I was examining so gently brought back unwanted memories of the night before. I don't think that I am about to become a vegetarian, but I may be turning into a reluctant carnivore.