Haematuria Causes And Workup

Learning Objectives

• To be able to enumerate causes of hematuria

• To be able take elaborate history and conduct relevant clinical examination

• To be able to make a diagnosis.

• To be able to suggest and interpret relevant investigations

Hematuria

• Gross blood in urine

• Microscopic 3 to 5 RBCs per HPF

• Always abnormal = whether macro, micro, single episode or patient on anticoagulants

• Terminal : proximal urethra, baldder neck/trigone, Iniial: distal to ext sphincter, total baldder / upper tract ( basis of 3 glass test)

• History & exam not sufficent to make diagnosis, so always needs investigations.

• Degree bears no relation with severity of disease. Always take it serious until proved otherwise.

Surgical Causes

• Kidneys– Congenital – polycystic, PUJ, medullary sponge kidney– Trauma – stone, rupture, runner’s hematuria– Inflammation – Nonspecific, TB, – Neoplastic – RCC, TCC pelvis, Wilm’s– papillary necrosis– Vascular / Congestion – AV malformations, RHF,renal vein

thrombosis,– Infarction – arterial thrombosis / embolism– Glomerular disorders – glomerulonephritis, IgA nephropathy,

Benign idiopathic hematuria– Lymphoma, multiple myeloma, amiloidosiss

Surgical Causes

– Ureters• Stones, TCC ureter, VUR, stricture,

• Bladder – Trauma, stone, catheter trauma– Inflammation – cystitis, TB, Bilharzia, post-

radiation cystitis, cyclophosphamide chemo.– Neoplastic – TCC, adeno squaamous

• Prostate– BPH, CaP, prostititis,

Surgical Causes

• Urethra– Trauma, rupture, stone, catheter trauma– Inflmmation – urethritis– Neoplaastic – TCC urethra, penile Ca– Atrophic urethritis

Surgical Causes

• Miscellaneous – Endometriosis – Diverticulitis– Appendicitis– Abdominal aortic aneurysm– Foreign body

Surgical Causes

• False hematuria food colors / drugs staining red (beet roots, Dindevan, pyridium,furadantin, rifampicin,= differentiation made with microscopy (RBCs)

• False +ve dipstick test.hemoblobin, erthrocytes, myoblobin, pigmenturia. DD= microscopy

• Factitious = source outside urinary system– Vaginal bleeding, malingering

Medical Causes

• Systemic disorders– Haematological

• Bleeding disorders– purpura, sickle cell disease, hemophilia, scurvy

• therapeutic anticoagulants,

• Malaria, SLE, Henoch Schonlein purpura, hypersensitivity angiitis, bacterial endocarditis, Wegener’s granulomatosis, Good pastures Syndrome

Points in history• Pain – renal, ureteric stone, clot, cysts, hydronephrosis, adv.

Tumors, trauma• Trauma, wt. loss, LUTS, dysuria, fever, riger, constitutional

symptoms• Pattern of hematuria- gross, micro, partial, total,

persistant/continuous, intermittent,• Clots long threadlike, amorphous, fresh, old• Smoking, occupaton, travel to schist areas, • Rash, joint paain (SLE)• URTI-PSGN• Purpura, rash, echymosis, easy bruiseability, bleed from multiple

sites• Medication – color, anticoagulants• Exercise, sepsis, systemic diseases = liver, renal failue• Mass, TB

Clinical examination• No physical sign / Anything could be found • Disoriented – liver / renal failue• Catheter / irrigation / drip / canulla• Pain agony – stone, HN, retention• Cechhexia, • Pulse shock, sepsis• BP , normal, shock, high ( HTN, renal failure)• Temp infection• Resp renal failure, acidosis• Purpura, rash, echymosis• Pallor / degree, anemia hematuria, renal failure• Jaundice, edema, L.nodes• Palpable visreras, L,S,K,K,UB,LN, masses,• prostate, urethra, testes, epid- vas (TB), meatus,stricure, retention

Workup

• Esteblish hematuria - dipstick

• Urine RE/microsscopy-RBCs

• Urine CS – infection, doesn’t rule out other causes

Imaging: US

• cheap, easy, easily available, noninvasive, no countraindication, nontoxic, no side eff/reaction

• Kidney: size, echogenicity, cortical thickness, cysts, mass, hydronephrosis, stone, C/m ratio

• Ureter: dilated, stonne, mass, ureterocele• Blaadder: stone, wall thickness / smooth, mass,

clot, diverticula, capacity, pre- postvvoid vlo• Prostste size, echogenicity

Disadvantages US

• : good for renal parenchyma but not for pelvicaliceal system, ureter annd not very good for bladder – mas miss lesions. Observer dependant, inter and intraobserver variability

IVU

• Conventional• Invasive ( IV contrast, side eff/ adverse eff –

anaphylaxis, toxicity,- drug, radiation)• May not be diagnostic• Demonstrates anatomy –normal / cong abormalities and

function – secretion thru kidney, transport thru collecting system, storage in bladder and evacuation.

• Very good for pelvicaliceal system and ureter• ROS, filling defect, (mass, Radiolucent stone, clot,

fungus, FB

• Many would proceed to cystoscopy after USG leaving IVU

IVU• Principle • Indications

– Stone, hematuria, trauma, congenital abnormalities, mass, assessment of function, obstruction

• Preparation– Purgation, hydration

• Precautions– Not during pain, renal status, hydration, clear KUB, allergy

• Procedure– Test dose, procedure – timings

• Side / adverse reactions – management of • Contra-indications• Interpretation • Disadvantages • Constrast and other things required

Cystoscopy

• Visualizes lower tract starting at ext meatus, leading to bladder.( U, P, BN, )

• bladder – capacity, bleeding site, edema/ congestion,ulcer,

mass, granuloma, orifices, diverticula, trabeculations, stone,

• Biopsy, brushings cytology, • Retrograde uro/pyelography / uretero-renoscopy• USG+cystoscopy +/_ RPG ay obviate need for

IVU in most but not all cases, in which case a formal IVU or a constrast CT scan is required

Urinary cytology, flow cytometery, tumour markers-NMP22, BTA

• May be helpful, being noninvasive, but not established to a point to replace routine workup.

• Yield varies from study to study & grade and type lesion

Hematuria of obscure origin

• 20%• Just explain that investigations that are usually

carried oout have not demonstrated any cause - • Do reassure but Never explain that all is OK, a

future investigation may show some cause in evolution or appearing then

• Follow up is required• Emmergency cystoscope in cases of active

rebleed•