Alleged injury caused by cystoscopy
A 50-year-old man came to see Urologist A for evaluation of intermittent hematuria present for one year. The patient reported right flank and abdominal pain, irritative bladder symptoms, and recent onset nocturia.
Alleged injury caused by cystoscopy
A 50-year-old man came to see Urologist A for evaluation of intermittent hematuria present for one year. The patient reported right flank and abdominal pain, irritative bladder symptoms, and recent onset nocturia.
Presentation
On April 2, 2021, a 50-year-old man came to see Urologist A for evaluation of intermittent hematuria present for one year. The patient reported right flank and abdominal pain, irritative bladder symptoms, and recent onset nocturia.
The patient’s medical history included bilateral kidney stones, depression, anxiety, fatigue, smoking, drug and alcohol use, obesity, and restless leg syndrome. Surgical history included appendectomy and arm surgery.
Physician action
A urinalysis showed a large number of red blood cells with no bacteria. A CT performed in March was noted in the patient record as showing no genitourinary pathology.
During this April 2 visit, Urologist A performed an in-office cystoscopy to rule out any malignancies and any structural abnormalities or obstructions. Informed consent was obtained from the patient before the procedure.
The cystoscopy revealed no abnormalities of the urethra; no obstructions; and no malignancies found in the urinary tract. Urologist A diagnosed microscopic hematuria from a suspected renal leak and prescribed trimethoprim/sulfamethoxazole for a bacterial infection. A follow-up appointment was scheduled in one year.
The next day, the patient called Urologist A’s office to report fever. Urologist A changed the patient’s prescription from trimethoprim/sulfamethoxazole to amoxicillin/clavulanic due to a possible drug allergy.
On April 5, the patient went to a nearby emergency department (ED) with fever, pain during urination, lower abdominal tenderness primarily on the right side, and feeling unwell since April 3. The patient told the ED nurse that he had a cystoscopy on April 2, for suspected bladder cancer after hematuria for one year.
A urine sample taken in the ED showed a large amount of blood cells, small leukocytes, and negative nitrites. EM Physician A changed the patient’s antibiotic to ciprofloxacin and discharged the patient home to follow up with Urologist A.
On April 24, the patient returned to Urologist A for evaluation of his hematuria, which was now persistent. The results from blood samples and cultures taken at this visit were normal.
A renal ultrasound was performed on April 30 to assess the patient for bladder clots. The right kidney measured 10 cm in length with the left kidney measuring 9.5 cm. The renal echotexture was normal. No renal cysts, solid masses, or shadowing calculi in either kidney were seen. No hydronephrosis or perinephric fluid collections were noted. The renal ultrasound was documented as “normal,” and the urinary bladder was noted as appearing “unremarkable.”
On June 18, the patient went to Urologist B on referral from his primary care physician. The patient informed Urologist B that Urologist A “told him” that he injured his prostate during the April 2 cystoscopy and that all his infection symptoms began after the procedure. He was currently taking ciprofloxacin daily and had no history of urinary tract infections (UTIs).
Urologist B diagnosed the patient with acute prostatitis. At a follow up visit on July 7, Urologist B gave the patient injections of ceftriaxone and gentamicin sulfate to treat the prostatitis.
On October 9, the patient came to a surgical hospital where Urologist B performed an MRI fusion prostate biopsy. Imaging during the procedure showed the prostate to be 20 g, smooth and symmetric without nodularity or induration. The patient’s prostate specific antigen (PSA) was 11 ng/mL; a repeat PSA was 9.15 ng/mL. (A normal PSA for a 50-year-old patient would be below 3.5 ng/mL.)
The results from the biopsy indicated the patient had benign prostatic glands and stroma with chronic and active inflammation.
On March 7, 2022, the patient returned to Urologist A for a follow-up appointment. The patient expressed frustration over the prolonged hematuria, infection symptoms, bladder holding symptoms, and persistent clotting that he believed were caused by the cystoscopy performed on April 2, 2021.
The patient continued treatment with Urologist B and his condition improved. Over the next nine months his nocturia resolved; his urine flow was described as slow to normal; and his PSA levels were normal. The intermittent hematuria continued.
Allegations
The patient filed a lawsuit against Urologist A alleging:
- unnecessary performance of a cystoscopy;
- negligence in injuring the prostate during the procedure; and
- failure to diagnose and appropriately treat the patient’s complications.
Legal implications
Urologists reviewing this case for the defense were supportive of the care provided by Urologist A and described his actions as within the standard of care. Due to the patient’s condition and symptoms — a 50-year-old smoker with a one-year history of hematuria and no UTIs — performing a cystoscopy was reasonable to rule out bladder cancer.
Documentation confirmed that the risks and benefits of the procedure were discussed with the patient and informed consent was obtained. Bleeding and infection are known risks of in-office cystoscopy.
Though the patient developed fever and worsening hematuria after the cystoscopy, these symptoms were consistent with prostatitis. One urologist said that this diagnosis can “sometimes require months of oral antibiotics to treat.” The patient’s urinary symptoms and right flank pain were present for a year before he saw Urologist A, which could indicate a chronic issue not caused by the cystoscopy.
The plaintiff’s expert stated that performing a cystoscopy was contraindicated due to evidence of an acute urinary tract infection. He also claimed that Urologist A breached the standard of care due to the magnitude of the patient’s post-procedure symptoms, including increased bleeding, infection, and lesion on the prostate gland.
The defense argued that there were no prostatic injuries found by the MRI or other tests following the cystoscopy. Further, Urologist B treated the patient for prostatitis, not a traumatic prostate injury.
Disposition
The case was taken to trial, and the jury returned a verdict in favor of the defendant, Urologist A.
About diagnostic errors
Disclaimer
Presentation
On April 2, 2021, a 50-year-old man came to see Urologist A for evaluation of intermittent hematuria present for one year. The patient reported right flank and abdominal pain, irritative bladder symptoms, and recent onset nocturia.
The patient’s medical history included bilateral kidney stones, depression, anxiety, fatigue, smoking, drug and alcohol use, obesity, and restless leg syndrome. Surgical history included appendectomy and arm surgery.
Physician action
A urinalysis showed a large number of red blood cells with no bacteria. A CT performed in March was noted in the patient record as showing no genitourinary pathology.
During this April 2 visit, Urologist A performed an in-office cystoscopy to rule out any malignancies and any structural abnormalities or obstructions. Informed consent was obtained from the patient before the procedure.
The cystoscopy revealed no abnormalities of the urethra; no obstructions; and no malignancies found in the urinary tract. Urologist A diagnosed microscopic hematuria from a suspected renal leak and prescribed trimethoprim/sulfamethoxazole for a bacterial infection. A follow-up appointment was scheduled in one year.
The next day, the patient called Urologist A’s office to report fever. Urologist A changed the patient’s prescription from trimethoprim/sulfamethoxazole to amoxicillin/clavulanic due to a possible drug allergy.
On April 5, the patient went to a nearby emergency department (ED) with fever, pain during urination, lower abdominal tenderness primarily on the right side, and feeling unwell since April 3. The patient told the ED nurse that he had a cystoscopy on April 2, for suspected bladder cancer after hematuria for one year.
A urine sample taken in the ED showed a large amount of blood cells, small leukocytes, and negative nitrites. EM Physician A changed the patient’s antibiotic to ciprofloxacin and discharged the patient home to follow up with Urologist A.
On April 24, the patient returned to Urologist A for evaluation of his hematuria, which was now persistent. The results from blood samples and cultures taken at this visit were normal.
A renal ultrasound was performed on April 30 to assess the patient for bladder clots. The right kidney measured 10 cm in length with the left kidney measuring 9.5 cm. The renal echotexture was normal. No renal cysts, solid masses, or shadowing calculi in either kidney were seen. No hydronephrosis or perinephric fluid collections were noted. The renal ultrasound was documented as “normal,” and the urinary bladder was noted as appearing “unremarkable.”
On June 18, the patient went to Urologist B on referral from his primary care physician. The patient informed Urologist B that Urologist A “told him” that he injured his prostate during the April 2 cystoscopy and that all his infection symptoms began after the procedure. He was currently taking ciprofloxacin daily and had no history of urinary tract infections (UTIs).
Urologist B diagnosed the patient with acute prostatitis. At a follow up visit on July 7, Urologist B gave the patient injections of ceftriaxone and gentamicin sulfate to treat the prostatitis.
On October 9, the patient came to a surgical hospital where Urologist B performed an MRI fusion prostate biopsy. Imaging during the procedure showed the prostate to be 20 g, smooth and symmetric without nodularity or induration. The patient’s prostate specific antigen (PSA) was 11 ng/mL; a repeat PSA was 9.15 ng/mL. (A normal PSA for a 50-year-old patient would be below 3.5 ng/mL.)
The results from the biopsy indicated the patient had benign prostatic glands and stroma with chronic and active inflammation.
On March 7, 2022, the patient returned to Urologist A for a follow-up appointment. The patient expressed frustration over the prolonged hematuria, infection symptoms, bladder holding symptoms, and persistent clotting that he believed were caused by the cystoscopy performed on April 2, 2021.
The patient continued treatment with Urologist B and his condition improved. Over the next nine months his nocturia resolved; his urine flow was described as slow to normal; and his PSA levels were normal. The intermittent hematuria continued.
Allegations
The patient filed a lawsuit against Urologist A alleging:
- unnecessary performance of a cystoscopy;
- negligence in injuring the prostate during the procedure; and
- failure to diagnose and appropriately treat the patient’s complications.
Legal implications
Urologists reviewing this case for the defense were supportive of the care provided by Urologist A and described his actions as within the standard of care. Due to the patient’s condition and symptoms — a 50-year-old smoker with a one-year history of hematuria and no UTIs — performing a cystoscopy was reasonable to rule out bladder cancer.
Documentation confirmed that the risks and benefits of the procedure were discussed with the patient and informed consent was obtained. Bleeding and infection are known risks of in-office cystoscopy.
Though the patient developed fever and worsening hematuria after the cystoscopy, these symptoms were consistent with prostatitis. One urologist said that this diagnosis can “sometimes require months of oral antibiotics to treat.” The patient’s urinary symptoms and right flank pain were present for a year before he saw Urologist A, which could indicate a chronic issue not caused by the cystoscopy.
The plaintiff’s expert stated that performing a cystoscopy was contraindicated due to evidence of an acute urinary tract infection. He also claimed that Urologist A breached the standard of care due to the magnitude of the patient’s post-procedure symptoms, including increased bleeding, infection, and lesion on the prostate gland.
The defense argued that there were no prostatic injuries found by the MRI or other tests following the cystoscopy. Further, Urologist B treated the patient for prostatitis, not a traumatic prostate injury.
Disposition
The case was taken to trial, and the jury returned a verdict in favor of the defendant, Urologist A.
About diagnostic errors
Disclaimer
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