Download MBBS Urology Presentations 2 Approach To Hematuria Lecture Notes

HEMATURIA

UROLOGY

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? Hematuria is the presence of blood in the urine.

CLASSIFICATION

A) Based on Intensity:

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MICROSCOPIC HEMATURIA

> 3 RBCs/HPF is significant.

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GROSS HEMATURIA

It is visible hematuria that can result

from as little as one ml of blood

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Gross versus Microscopic Hematuria.

The significance of gross versus microscopic hematuria is simply that

the chances of identifying significant pathology increase with the

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degree of hematuria.

The patients with gross hematuria usually have identifiable underlying

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pathology

It is common for patients with minimal degrees of microscopic

hematuria to have a negative urologic evaluation.

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CLASSIFICATION

B) Based on Origin:
1- Glomerular

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2- Non-glomerular
C) Based on Relation to micturition:

1- Total hematuria(MC) is present all over the voided urine. Underlying

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pathology may be in kidney, ureter, bladder or prostate or systemic.


Bleeding from kidney is associated with cylindrical worm-like clots.

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Hematuria from bladder and prostate is associated with big irregular

or discoid clots.

2- Terminal hematuria at the end of micturition is of vesical origin e.g.

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active bilharzial cystitis.

It is usually due to bladder neck or prostatic inflammation.

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It occurs at the end of micturition as the bladder neck contracts,

squeezing out the last amount of urine.

3- Initial hematuria at the beginning of micturition indicates urethral

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pathology.


Timing during micturition

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Urethra

Trigone

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Bladder neck

Posterior

urethra

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Bladder

Upper urinary

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tract

D) Based on Associated symptoms:

Painless hematuria: No other urinary symptoms: All cases should be

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investigated for urologic malignancy.

Bladder cancer is the most common and should be excluded.

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Hematuria associated with other symptoms:
Simple cystitis: frequency, burning, urgency and terminal hematuria.
Malignant cystitis: severe frequency, pain, urge incontinence, total

hematuria with clots or necroturia

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Ureteral obstruction due to blood clots is the most common cause of

pain associated with gross hematuria.

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Stones: Renal pain.
BPH, prostate cancer: associated LUTS (prostatism).
Surgical trauma to kidney and bladder e.g. PCNL & TURBT.
E) Based on Etiology:

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General or systemic:

Bleeding disorder: thrombocytopenic purpura, leukemia, hemophilia.

Liver cirrhosis.

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Anticoagulants.

Hypertension.

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Renal causes:

A) Nephrologic: dysmorphic RBCs
Acute glomerulonephritis is the most common cause in children and

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young adults. It is associated with proteinuria.


B) Urologic: Eumorphic RBCs - oval
Congenital: Polycystic kidney.

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Inflammation: Pyelonephritis, TB.
Trauma: Accidents, Iatrogenic.
Stones
Kidney cancer
Vascular: Hemangiomas, AV fistula.

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Nephrologic origin

.

? Casts

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? Almost always significant proteinuria(often 100 to 300

mg/dL /2+ to 3+ range on dipstick).

Urologic origin

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? Even significant hematuria of urologic origin will not

elevate the protein concentration in the urine in

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above range.

Glomerular

qPresence of Dysmorphic RBC, RBC casts, and proteinuria.

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IgA nephropathy (Berger disease) 30%
Mesangioproliferative GN
Focal segmental proliferative GN
Familial nephritis (e.g., Alport syndrome)

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Membranous GN
Focal segmental sclerosis
Systemic lupus erythematosus
Postinfectious GN
Subacute bacterial endocarditis

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NONGLOMERULAR

Medical or Surgical

qMedical-

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1. Tubulointerstitial
2. Renovascular, or systemic disorders.

Medical

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Blood dyscrasia
Familial urolithiasis
MSK & ADPKD
Papillay necrosis
Uncorrected coagulopathy

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Medication (G/NG)
Exercise-induced haematuria ( G/NG)
Vascular disease ( RAE,RVT, AV ,CVD,

INFRACT)

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Vascular disease may also result in nonglomerular hematuria like

1.

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Renal artery embolism and thrombosis

2.

Arteriovenous fistulae, and

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3.

Renal vein thrombosis.

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Physical examination may reveal

1.

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severe hypertension

2.

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flank or abdominal bruit, or

3.

atrial fibrillation.

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In such patients, further evaluation for renal vascular disease should

be undertaken.

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Surgical / Essential

TUMOR, STONE , UTI & TRAUMA.

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Ureteral:

Stones.
Iatrogenic trauma e.g. ureteroscopy.
Tumors: TCC of pelvis and ureter.

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Bladder:

Bladder cancer is the most common cause of gross hematuria in a

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patient above 60 years.

Cystitis: Bacterial, bilharzial, T.B.
Stones
Trauma e.g. post TURBT

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Prostate

BPH
Prostate cancer
Prostatitis

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Surgical: after prostatectomy


Posterior urethra:

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Inflammation
Trauma
Tumor

EVALUATION

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Hematuria of any degree should never be ignored

In adults, should be regarded as a symptom of urologic malignancy until

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proved otherwise.


History -
Questions should always be asked

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1) Is the hematuria gross or microscopic?

2) At what time during urination does the hematuria occur (beginning

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or end of stream or during entire stream)?

3) Is the hematuria associated with pain?

4) Is the patient passing clots?

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5) If the patient is passing clots, do the clots have a specific shape?

The answers will enable the urologist to target the subsequent

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diagnostic evaluation efficiently

Discoloration of urine

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Association with Pain:

Hematuria, although frightening, is usually not painful unless it is

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associated with inflammation or obstruction.

Thus patients with cystitis and secondary hematuria may experience

painful urinary irritative symptoms

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The pain is usually not worsened with passage of clots.

Pain in association with hematuria usually results from upper urinary

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tract hematuria with obstruction of the ureters with clots.

Passage of these clots may be associated with severe, colicky flank pain

similar to that produced by a ureteral calculus

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This helps identify the source of the hematuria.
Association with Clots:

The presence of clots usually indicates a more significant degree of

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hematuria

Accordingly, the probability of identifying significant urologic

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pathology increases.

Shape of Clots:

Amorphous : bladder origin or Prostatic urethral origin

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Vermiform (wormlike) clots, particularly

If associated with flank pain,

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Hematuria coming from the upper urinary tract,

Suggests from within the ureter.

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Shape of clots

Examinations

General examination- Vitals

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Pallor ,
Diffuse bruise

Per abdomen ? Suprapubic fullness or mass
Fullness or mass in lumber area

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External genitalia- Blood at meatus, haematoma, tumor

DRE- Hard /nodular prostate
Investigations

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Routine and microscopic examination
Urine cytology
Cystoscopy
Urinary tract imaging ( CT/IVU)

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Haematuria detection in urine

Dipstick detection of hematuria sensitivity of over 90%

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Detection of blood is due to peroxidase-like activity of

hemoglobin.

Hb catalyzes the oxidation of a chromogen indicator

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color change in direct proportion to the amount of

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blood in urine

The results of urine dipstick tests must be confirmed on

urinalysis with microscopy.

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Hematuria v/s hemoglobinuria and myoglobinuria

Hematuria, hemoglobinuria, and myoglobinuria will all result

in positive dipstick for blood

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Differentiation is done by microscopic examination of the

centrifuged urine

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Erythrocytes present = Hematuria.

Erythrocytes are absent = Hemoglobinuria
Myoglobinuria

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Haemoglobinuria vs Myoglobinuria

A sample of blood is centrifuged.
In hemoglobinuria, the supernatant will be pink.
This is because free hemoglobin in the serum binds to

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haptoglobin


water insoluble and has a high molecular

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weight

complex remains in the serum & gives a pink
color
In myoglobinuria, the myoglobin released from

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muscle is of low molecular weight and water soluble.

It does not bind to haptoglobin and is therefore

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excreted immediately into the urine.

Therefore in myoglobinuria the serum remains clear

There is also a higher false-positive rate & causes include

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(i) Urine contamination with menstrual blood
(ii) Dehydration
(iii) Exercise
(iv) Oxidizing agents
(v) Bacterial peroxidase

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MICROSCOPY

These erythrocytes may or may not retain their hemoglobin ("ghost cells")

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RBC in Ca Bladder


Red cell Casts in Urine

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Red cell casts indicate

renal hematuria
Red cell casts may

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appear brown to almost

colorless and are usually

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diagnostic of glomerular

disease

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Cystoscopy

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IVP/CT scan


Algorithm for diferential diagnosis of

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glomerular hematuria

Algorithm for diferential diagnosis of nonglomerular

renal hematuria

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IgA Nephropathy (Berger Disease):

IgA nephropathy, or Berger disease, is the most common cause of

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glomerular hematuria.

Accounts for about 30% of cases

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Nephropathy occurs most commonly in children and young adults,

with a male predominance.

Patients typically present with hematuria after an upper respiratory

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tract infection or exercise
Hematuria may be associated with a low-grade fever or rash.

Most patients have no associated systemic symptoms.

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Gross hematuria occurs intermittently, but microscopic hematuria is a

constant finding in some patients.

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The disease is chronic.

Prognosis in most patients is excellent.

Pathologic findings in Berger disease are limited to either focal

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glomeruli or lobular segments of a glomerulus.

The changes are proliferative and usually confined to mesangial cells.

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The presence of RBC casts establishes the glomerular origin of the

hematuria.

Renal biopsy reveals deposits of immunoglobulins in mesangial cells.

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1.

IgA

2.

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IgG, and

3.

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1c-globulin.
Management

Goals for treatment of macroscopic haematuria

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R?resuscitate as appropriate
E?ensure that urine can drain freely with or without

catheter insertion

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S?safe discharge from the ED where appropriate
P?prompt followup and further investigation

Management

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Initial management

Catheterisation and irrigation with saline/glycine
Clot evacuation
Fulgaration

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Toomy's syringe Clot evacuation

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Ellick's evacuator


Haemorrhagic cystitis:

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Intractable hematuria localized in the bladder

Hemorrhagic cystitis is characterized by diffuse

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inflammation and bleeding from the bladder mucosa

Causes of haemorrhagic cystitis:

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Management of haemorrhagic cystitis:

Haematuria continues
Renal cell carcinoma
1. Localised

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2. Locally advanced
3. Metastatic

Upper tract TCC
1. Localised

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2. Locally advanced
3. Metastatic

carcinoma bladder

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Histology

? 90-95%

transitional-cell carcinoma

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? 3%

squamos-cell carcinoma

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? 2%

adenocarcinoma

? <1%

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smal -cell carcinoma

? 99%

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primary tumors
Entities

? 75-85%

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superficial bladder cancer

pTa, pTis, pT1

? 10-15%

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muscle-invasive bladder cancer

pT2, pT3, pT4

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? 5%

metastatic bladder cancer

N+, M+

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Superficial Bladder Cancer - TURBT

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TURBT

Superficial Bladder Cancer - TURBT

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Invasive bladder cancer

? Standard of care = Radical cystectomy with urinary

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diversion with pelvic lymphadenectomy

? Only about 50% of patients with high-grade

invasive disease are cured

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Radical cystectomy


Urinary diversion

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? Uretero ? sigmoidostomy

? Ileal conduit

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? Colon conduit

? Ileocaecal segment

? Orthotopic neobladder

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Cutaneous urinary

diversions

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Ileal conduit (ileal loop)

A 15 cm loop of ileum led out

through abdominal wall

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Stents used

The space at cystectomy site

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drained by a drainage system

After surgery a skin barrier

and a transparent disposable

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urinary drainage bag

Constantly drains

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Haematuria from prostatic origin:

Hematuria from prostatic origin is a diagnosis made after

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a complete evaluation (including cytology, upper tract

imaging, and cystoscopy) to confirm that no other source

of hematuria exists.

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Most common causes are:

BPH
Prostate carcinoma

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Prostatits

BPH -> m/c cause of prostate-related bleeding

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Haematuria of urethral origin:

Urethral bleeding (urethrorrhagia) is defined as

bleeding distal to the bladder neck, occurring separate

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from micturition

Blood at the urethral meatus in the absence of

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volitional micturition, initial hematuria, or blood at

the start of urination frequently implies pathologic

processes distal to the external urinary sphincter.

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Causes of urethral bleeding:
RGU and cystourethroscopy remain the mainstays for

diagnosis in patients with suspected urethral bleeding

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Perineal or penile bruising, accompanied by a

hematoma, often is a clear indication of injury related

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to trauma.

RGU is essential in instances of trauma when a

urethral injury is suspected

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ASYMTOMATIC MICROHAEMATURIA:

The American Urological Association (AUA) has published

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guidelines regarding patients with asymptomatic

microhematuria (AMH)

It is defined as three or more RBCs per HPF in the absence

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of an obvious benign cause.

A determination of AMH should be based on microscopic,

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not dipstick, examination of the urine.
To rule out benign causes of AMH, such as
1.

Infection

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2. Medical renal disease, and others.

Careful history

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Physical examination

Laboratory examination should be done

Once these causes are ruled out, urologic evaluation that

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includes a measurement of renal function is recommended.

If factors such as dysmorphic RBCs, proteinuria, casts, or

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renal insufficiency are present, nephrologic workup should

be considered in addition to the urologic evaluation.

AMH that occurs in patients who are anticoagulated still

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warrants urologic evaluation.
The evaluation of patients over 35 years of age with AMH

should include cystoscopy

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It is optional in younger patients.

All patients should have cystoscopy if risk factors such as
1. Irritative voiding symptoms

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2. Tobacco use, or
3. Chemical exposures are present.

Radiologic evaluation should be performed in the initial

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evaluation

The procedure of choice is multiphasic CT urography
with and without IV contrast.

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Magnetic resonance urography, with or without IV

contrast, is an acceptable alternative in patients who

cannot undergo multiphasic CT scan.

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In cases where collecting system detail is needed and there

is a contraindication to the use of IV contrast , options are:

1. Noncontrast CT

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2. MRI or

3. Renal ultrasonography with retrograde pyelograms is an

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acceptable alternative.

Cytology may be useful in those patients with persistent

AMH

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Following a negative workup

Those with other risk factors for carcinoma in situ,
such as

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1. Irritative voiding symptoms
2. Use of tobacco, or
3. Chemical exposures.

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Patients with persistent AMH:

Yearly urinalysis should be performed.

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The presence of two consecutive annual negative

urinalyses indicates that no further urinalyses are needed

for this purpose.

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For patients with persistent or recurrent AMH, repeat

evaluation within 3 to 5 years should be considered.

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Management algorithm of asymptomatic microhaematuria: