CLASSIFICATION
A) Based on Intensity:
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MICROSCOPIC HEMATURIA
> 3 RBCs/HPF is significant.
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GROSS HEMATURIAIt 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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pathologyIt 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-glomerularC) 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 irregularor 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 neckPosterior
urethra
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Bladder
Upper urinary
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tractD) 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 300mg/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 GNFocal segmental sclerosis
Systemic lupus erythematosus
Postinfectious GN
Subacute bacterial endocarditis
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NONGLOMERULARMedical or Surgical
qMedical-
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1. Tubulointerstitial2. Renovascular, or systemic disorders.
Medical
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Blood dyscrasiaFamilial 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 thrombosis2.
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, or3.
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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ProstateBPH
Prostate cancer
Prostatitis
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Surgical: after prostatectomyPosterior urethra:
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InflammationTrauma
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 efficientlyDiscoloration 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 clotsExaminations
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 ofhemoglobin.
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 urineThe results of urine dipstick tests must be confirmed on
urinalysis with microscopy.
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Hematuria v/s hemoglobinuria and myoglobinuriaHematuria, 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 MyoglobinuriaA 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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weightcomplex 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 glomerulardisease
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IVP/CT scanAlgorithm for diferential diagnosis of
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glomerular hematuriaAlgorithm 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 thehematuria.
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 appropriateE?ensure that urine can drain freely with or without
catheter insertion
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S?safe discharge from the ED where appropriateP?prompt followup and further investigation
Management
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Initial managementCatheterisation 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 mucosaCauses of haemorrhagic cystitis:
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Management of haemorrhagic cystitis:Haematuria continues
Renal cell carcinoma
1. Localised
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2. Locally advanced3. Metastatic
Upper tract TCC
1. Localised
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2. Locally advanced3. 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 tumorsEntities
? 75-85%
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superficial bladder cancerpTa, 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 systemAfter 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 tractimaging, 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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ProstatitsBPH -> 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 atthe 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 asymptomaticmicrohematuria (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 examinationLaboratory 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 shouldbe 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, or3. Chemical exposures are present.
Radiologic evaluation should be performed in the initial
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evaluationThe procedure of choice is multiphasic CT urography
with and without IV contrast.
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Magnetic resonance urography, with or without IVcontrast, 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 thereis 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 negativeurinalyses 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: