Download MBBS Urology Presentations 2 Approach To Hematuria Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) 1st Year, 2nd Year, 3rd Year and Final year Urology 2 Approach To Hematuria PPT-Powerpoint Presentations and lecture notes



? Hematuria is the presence of blood in the urine.


A) Based on Intensity:


> 3 RBCs/HPF is significant.


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


It is common for patients with minimal degrees of microscopic

hematuria to have a negative urologic evaluation.


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


Timing during micturition



Bladder neck




Upper urinary


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.



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.
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.


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

Medical or Surgical

1. Tubulointerstitial
2. Renovascular, or systemic disorders.


Blood dyscrasia
Familial urolithiasis
Papillay necrosis
Uncorrected coagulopathy
Medication (G/NG)
Exercise-induced haematuria ( G/NG)
Vascular disease ( RAE,RVT, AV ,CVD,


Vascular disease may also result in nonglomerular hematuria like


Renal artery embolism and thrombosis


Arteriovenous fistulae, and


Renal vein thrombosis.

Physical examination may reveal


severe hypertension


flank or abdominal bruit, or


atrial fibrillation.

In such patients, further evaluation for renal vascular disease should

be undertaken.

Surgical / Essential



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


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

patient above 60 years.

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

Prostate cancer
Surgical: after prostatectomy

Posterior urethra:



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


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


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

Routine and microscopic examination
Urine cytology
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


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

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


water insoluble and has a high molecular

complex remains in the serum & gives a pink
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


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



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


Renal biopsy reveals deposits of immunoglobulins in mesangial cells.



IgG, and



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


Initial management

Catheterisation and irrigation with saline/glycine
Clot evacuation

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


? 90-95%

transitional-cell carcinoma

? 3%

squamos-cell carcinoma

? 2%


? <1%

smal -cell carcinoma

? 99%

primary tumors

? 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


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


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:

Prostate carcinoma

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


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


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


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


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