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HEMATURIA
UROLOGY
? Hematuria is the presence of blood in the urine.
CLASSIFICATION
A) Based on Intensity:
MICROSCOPIC HEMATURIA
> 3 RBCs/HPF is significant.
GROSS HEMATURIA
It is visible hematuria that can result
from as little as one ml of blood
Gross versus Microscopic Hematuria.
The significance of gross versus microscopic hematuria is simply that
the chances of identifying significant pathology increase with the
degree of hematuria.
The patients with gross hematuria usually have identifiable underlying
pathology
It is common for patients with minimal degrees of microscopic
hematuria to have a negative urologic evaluation.
CLASSIFICATION
B) Based on Origin:
1- Glomerular
2- Non-glomerular
C) Based on Relation to micturition:
1- Total hematuria(MC) is present all over the voided urine. Underlying
pathology may be in kidney, ureter, bladder or prostate or systemic.
Bleeding from kidney is associated with cylindrical worm-like clots.
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.
active bilharzial cystitis.
It is usually due to bladder neck or prostatic inflammation.
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
pathology.
Timing during micturition
Urethra
Trigone
Bladder neck
Posterior
urethra
Bladder
Upper urinary
tract
D) Based on Associated symptoms:
Painless hematuria: No other urinary symptoms: All cases should be
investigated for urologic malignancy.
Bladder cancer is the most common and should be excluded.
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
Ureteral obstruction due to blood clots is the most common cause of
pain associated with gross hematuria.
Stones: Renal pain.
BPH, prostate cancer: associated LUTS (prostatism).
Surgical trauma to kidney and bladder e.g. PCNL & TURBT.
E) Based on Etiology:
General or systemic:
Bleeding disorder: thrombocytopenic purpura, leukemia, hemophilia.
Liver cirrhosis.
Anticoagulants.
Hypertension.
Renal causes:
A) Nephrologic: dysmorphic RBCs
Acute glomerulonephritis is the most common cause in children and
young adults. It is associated with proteinuria.
B) Urologic: Eumorphic RBCs - oval
Congenital: Polycystic kidney.
Inflammation: Pyelonephritis, TB.
Trauma: Accidents, Iatrogenic.
Stones
Kidney cancer
Vascular: Hemangiomas, AV fistula.
Nephrologic origin
.
? Casts
? Almost always significant proteinuria(often 100 to 300
mg/dL /2+ to 3+ range on dipstick).
Urologic origin
? Even significant hematuria of urologic origin will not
elevate the protein concentration in the urine in
above range.
Glomerular
qPresence of Dysmorphic RBC, RBC casts, and proteinuria.
IgA nephropathy (Berger disease) 30%
Mesangioproliferative GN
Focal segmental proliferative GN
Familial nephritis (e.g., Alport syndrome)
Membranous GN
Focal segmental sclerosis
Systemic lupus erythematosus
Postinfectious GN
Subacute bacterial endocarditis
NONGLOMERULAR
Medical or Surgical
qMedical-
1. Tubulointerstitial
2. Renovascular, or systemic disorders.
Medical
Blood dyscrasia
Familial urolithiasis
MSK & ADPKD
Papillay necrosis
Uncorrected coagulopathy
Medication (G/NG)
Exercise-induced haematuria ( G/NG)
Vascular disease ( RAE,RVT, AV ,CVD,
INFRACT)
Vascular disease may also result in nonglomerular hematuria like
1.
Renal artery embolism and thrombosis
2.
Arteriovenous fistulae, and
3.
Renal vein thrombosis.
Physical examination may reveal
1.
severe hypertension
2.
flank or abdominal bruit, or
3.
atrial fibrillation.
In such patients, further evaluation for renal vascular disease should
be undertaken.
Surgical / Essential
TUMOR, STONE , UTI & TRAUMA.
Ureteral:
Stones.
Iatrogenic trauma e.g. ureteroscopy.
Tumors: TCC of pelvis and ureter.
Bladder:
Bladder cancer is the most common cause of gross hematuria in a
patient above 60 years.
Cystitis: Bacterial, bilharzial, T.B.
Stones
Trauma e.g. post TURBT
Prostate
BPH
Prostate cancer
Prostatitis
Surgical: after prostatectomy
Posterior urethra:
Inflammation
Trauma
Tumor
EVALUATION
Hematuria of any degree should never be ignored
In adults, should be regarded as a symptom of urologic malignancy until
proved otherwise.
History -
Questions should always be asked
1) Is the hematuria gross or microscopic?
2) At what time during urination does the hematuria occur (beginning
or end of stream or during entire stream)?
3) Is the hematuria associated with pain?
4) Is the patient passing clots?
5) If the patient is passing clots, do the clots have a specific shape?
The answers will enable the urologist to target the subsequent
diagnostic evaluation efficiently
Discoloration of urine
Association with Pain:
Hematuria, although frightening, is usually not painful unless it is
associated with inflammation or obstruction.
Thus patients with cystitis and secondary hematuria may experience
painful urinary irritative symptoms
The pain is usually not worsened with passage of clots.
Pain in association with hematuria usually results from upper urinary
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
This helps identify the source of the hematuria.
Association with Clots:
The presence of clots usually indicates a more significant degree of
hematuria
Accordingly, the probability of identifying significant urologic
pathology increases.
Shape of Clots:
Amorphous : bladder origin or Prostatic urethral origin
Vermiform (wormlike) clots, particularly
If associated with flank pain,
Hematuria coming from the upper urinary tract,
Suggests from within the ureter.
Shape of clots
Examinations
General examination- Vitals
Pallor ,
Diffuse bruise
Per abdomen ? Suprapubic fullness or mass
Fullness or mass in lumber area
External genitalia- Blood at meatus, haematoma, tumor
DRE- Hard /nodular prostate
Investigations
Routine and microscopic examination
Urine cytology
Cystoscopy
Urinary tract imaging ( CT/IVU)
Haematuria detection in urine
Dipstick detection of hematuria sensitivity of over 90%
Detection of blood is due to peroxidase-like activity of
hemoglobin.
Hb catalyzes the oxidation of a chromogen indicator
color change in direct proportion to the amount of
blood in urine
The results of urine dipstick tests must be confirmed on
urinalysis with microscopy.
Hematuria v/s hemoglobinuria and myoglobinuria
Hematuria, hemoglobinuria, and myoglobinuria will all result
in positive dipstick for blood
Differentiation is done by microscopic examination of the
centrifuged urine
Erythrocytes present = Hematuria.
Erythrocytes are absent = Hemoglobinuria
Myoglobinuria
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
haptoglobin
water insoluble and has a high molecular
weight
complex remains in the serum & gives a pink
color
In myoglobinuria, the myoglobin released from
muscle is of low molecular weight and water soluble.
It does not bind to haptoglobin and is therefore
excreted immediately into the urine.
Therefore in myoglobinuria the serum remains clear
There is also a higher false-positive rate & causes include
(i) Urine contamination with menstrual blood
(ii) Dehydration
(iii) Exercise
(iv) Oxidizing agents
(v) Bacterial peroxidase
MICROSCOPY
These erythrocytes may or may not retain their hemoglobin ("ghost cells")
RBC in Ca Bladder
Red cell Casts in Urine
Red cell casts indicate
renal hematuria
Red cell casts may
appear brown to almost
colorless and are usually
diagnostic of glomerular
disease
Cystoscopy
IVP/CT scan
Algorithm for diferential diagnosis of
glomerular hematuria
Algorithm for diferential diagnosis of nonglomerular
renal hematuria
IgA Nephropathy (Berger Disease):
IgA nephropathy, or Berger disease, is the most common cause of
glomerular hematuria.
Accounts for about 30% of cases
Nephropathy occurs most commonly in children and young adults,
with a male predominance.
Patients typically present with hematuria after an upper respiratory
tract infection or exercise
Hematuria may be associated with a low-grade fever or rash.
Most patients have no associated systemic symptoms.
Gross hematuria occurs intermittently, but microscopic hematuria is a
constant finding in some patients.
The disease is chronic.
Prognosis in most patients is excellent.
Pathologic findings in Berger disease are limited to either focal
glomeruli or lobular segments of a glomerulus.
The changes are proliferative and usually confined to mesangial cells.
The presence of RBC casts establishes the glomerular origin of the
hematuria.
Renal biopsy reveals deposits of immunoglobulins in mesangial cells.
1.
IgA
2.
IgG, and
3.
1c-globulin.
Management
Goals for treatment of macroscopic haematuria
R?resuscitate as appropriate
E?ensure that urine can drain freely with or without
catheter insertion
S?safe discharge from the ED where appropriate
P?prompt followup and further investigation
Management
Initial management
Catheterisation and irrigation with saline/glycine
Clot evacuation
Fulgaration
Toomy's syringe Clot evacuation
Ellick's evacuator
Haemorrhagic cystitis:
Intractable hematuria localized in the bladder
Hemorrhagic cystitis is characterized by diffuse
inflammation and bleeding from the bladder mucosa
Causes of haemorrhagic cystitis:
Management of haemorrhagic cystitis:
Haematuria continues
Renal cell carcinoma
1. Localised
2. Locally advanced
3. Metastatic
Upper tract TCC
1. Localised
2. Locally advanced
3. Metastatic
carcinoma bladder
Histology
? 90-95%
transitional-cell carcinoma
? 3%
squamos-cell carcinoma
? 2%
adenocarcinoma
? <1%
smal -cell carcinoma
? 99%
primary tumors
Entities
? 75-85%
superficial bladder cancer
pTa, pTis, pT1
? 10-15%
muscle-invasive bladder cancer
pT2, pT3, pT4
? 5%
metastatic bladder cancer
N+, M+
Superficial Bladder Cancer - TURBT
TURBT
Superficial Bladder Cancer - TURBT
Invasive bladder cancer
? Standard of care = Radical cystectomy with urinary
diversion with pelvic lymphadenectomy
? Only about 50% of patients with high-grade
invasive disease are cured
Radical cystectomy
Urinary diversion
? Uretero ? sigmoidostomy
? Ileal conduit
? Colon conduit
? Ileocaecal segment
? Orthotopic neobladder
Cutaneous urinary
diversions
Ileal conduit (ileal loop)
A 15 cm loop of ileum led out
through abdominal wall
Stents used
The space at cystectomy site
drained by a drainage system
After surgery a skin barrier
and a transparent disposable
urinary drainage bag
Constantly drains
Haematuria from prostatic origin:
Hematuria from prostatic origin is a diagnosis made after
a complete evaluation (including cytology, upper tract
imaging, and cystoscopy) to confirm that no other source
of hematuria exists.
Most common causes are:
BPH
Prostate carcinoma
Prostatits
BPH -> m/c cause of prostate-related bleeding
Haematuria of urethral origin:
Urethral bleeding (urethrorrhagia) is defined as
bleeding distal to the bladder neck, occurring separate
from micturition
Blood at the urethral meatus in the absence of
volitional micturition, initial hematuria, or blood at
the start of urination frequently implies pathologic
processes distal to the external urinary sphincter.
Causes of urethral bleeding:
RGU and cystourethroscopy remain the mainstays for
diagnosis in patients with suspected urethral bleeding
Perineal or penile bruising, accompanied by a
hematoma, often is a clear indication of injury related
to trauma.
RGU is essential in instances of trauma when a
urethral injury is suspected
ASYMTOMATIC MICROHAEMATURIA:
The American Urological Association (AUA) has published
guidelines regarding patients with asymptomatic
microhematuria (AMH)
It is defined as three or more RBCs per HPF in the absence
of an obvious benign cause.
A determination of AMH should be based on microscopic,
not dipstick, examination of the urine.
To rule out benign causes of AMH, such as
1.
Infection
2. Medical renal disease, and others.
Careful history
Physical examination
Laboratory examination should be done
Once these causes are ruled out, urologic evaluation that
includes a measurement of renal function is recommended.
If factors such as dysmorphic RBCs, proteinuria, casts, or
renal insufficiency are present, nephrologic workup should
be considered in addition to the urologic evaluation.
AMH that occurs in patients who are anticoagulated still
warrants urologic evaluation.
The evaluation of patients over 35 years of age with AMH
should include cystoscopy
It is optional in younger patients.
All patients should have cystoscopy if risk factors such as
1. Irritative voiding symptoms
2. Tobacco use, or
3. Chemical exposures are present.
Radiologic evaluation should be performed in the initial
evaluation
The procedure of choice is multiphasic CT urography
with and without IV contrast.
Magnetic resonance urography, with or without IV
contrast, is an acceptable alternative in patients who
cannot undergo multiphasic CT scan.
In cases where collecting system detail is needed and there
is a contraindication to the use of IV contrast , options are:
1. Noncontrast CT
2. MRI or
3. Renal ultrasonography with retrograde pyelograms is an
acceptable alternative.
Cytology may be useful in those patients with persistent
AMH
Following a negative workup
Those with other risk factors for carcinoma in situ,
such as
1. Irritative voiding symptoms
2. Use of tobacco, or
3. Chemical exposures.
Patients with persistent AMH:
Yearly urinalysis should be performed.
The presence of two consecutive annual negative
urinalyses indicates that no further urinalyses are needed
for this purpose.
For patients with persistent or recurrent AMH, repeat
evaluation within 3 to 5 years should be considered.
Management algorithm of asymptomatic microhaematuria:
This post was last modified on 08 April 2022