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Centrifuged urine In hemoglobinuria, the supernatant will be pink. This is because free hemoglobin in the serum binds to haptoglobin, which is water insoluble and has a high molecular weight. This complex remains in the serum, causing a pink color. Free hemoglobin will appear in the urine only when all of the haptoglobin-binding sites have been saturated.
Centrifuged urine 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.
Quantity of Hematuria Microscopic Hematuria : seen only under microscope Gross Hematuria : visible, urine is pink, cola, red 5 times the number of life-threatening conditions when compared with patients with microscopic hematuria.
If the patient is passing clots, do the clots have a specific shape?
Timing of Hematuria Frequently indicating the site of origin as Initial hematuria from urethra, least common, usually secondary to inflammation Terminal hematuria secondary to inflammation at bladder neck or prostatic urethra Total hematuria from bladder or upper tract, most common
Total Hematuria Terminal Hematuria Initial Hematuria
Amorphous clots : bladder or prostatic urethral origin
Vermiform (wormlike) clots, particularly if associated with flank pain : the upper urinary tract : ureter
Duration of Hematuria Transient Hematuria Benign & without any obvious etiology in 39%of young adults 8-9% of adults >50y/o – malignancy Persistent Hematuria Defined as three positive urinalyses, based on a test strip and microscopic examination, over a 2- to 3- week period Microscopic – 5% malignancy Macroscopic – 20% malignancy
Non-glomerular Hematuria Non-glomerular hematuria or essential hematuria includes primarily urologic rather than nephrologic diseases Common causes of essential hematuria include urologic tumors, stones, and UTIs
Non-glomerular Hematuria Characterized by circular erythrocytes and the absence of erythrocyte casts
An algorithm for the evaluation of nonglomerular hematuria
Urine culture : A midstream or clean-catch specimen of urine should be obtained for culture sensitivity whenever a urinary tract infection is suspected.
Work-up : Imaging Studies
Renal and bladder ultrasonography
Urinary tract anomalies, such as hydronephrosis, hydroureter, nephrocalcinosis, tumor, and urolithiasis, are readily revealed with ultrasonography
Compared with other imaging studies, sonography is rapid, noninvasive, readily available, and devoid of exposure to radiation
In individuals with severe obesity, a more accurate definition of renal structures and surrounding organs can be achieved using only CT scanning
Work-up : Imaging Studies
Other imaging studies
A spiral CT scan is particularly useful in the detection of urolithiasis, Wilms tumor, and polycystic kidney disease
Voiding cystourethrograms are valuable in detecting urethral and bladder abnormalities that may result in hematuria (eg, cystitis)
Radionuclide studies can be helpful in the evaluation of obstructing calculi
Microscopy of urinary sediment. Typical appearance in non-glomerular hematuria: RBCs are uniform in size and shape but show two populations of cells because a small number have lost their hemoglobin pigment
Microscopy of urinary sediment. A cast containing numerous erythrocytes, indicating glomerulonephritis
Persistent microscopic Hematuria Evidence of glomerular disease Yes No Renal parenchymal disease evaluation Urologic evaluation Renal Biopsy Risk of urologic malignancy
ureteral or pelvic stones, strictures and tumor
History taking: Present Illness Symptoms Lower urinary tract (urethra and bladder) -hesitancy -lessened force and size of the stream -terminal dribbling
History taking: Present Illness 2.Upper urinary tract ( ureter and kidney) -pain in the flank radiating along the course of the ureter -gross hematuria (from stone) -GI symptoms -fever with chills - may be asymptomatic
3. Ureteral changes: distention, dilatation and hydroureter
4. Pelvicalyceal changes: first shows evidence of hyperactivity and hypertrophy and then progressive dilatation and followed by flattening of the papillae and finally clubbing of the minor calyces. 5. Renal Parenchymal Changes : compression, ischemic atrophy.
Clinical findings 1.Symptoms and signs: infravesical obstruction :difficulty of voiding,weak stream ,diminished flow rate,terminal dribbling,burning ,frequency. Supravesical obstruction :renal pain or renal colic,if gradually--asymptomatic or enlarged kidney
Clinical findings 2.Laboratory findings Urinalysis BUN Creatinine Impaired kidney function elevated blood urea nitrogen and serum creatinine
Clinical findings 3.X-Ray findings , IVP, Cystoscopy , Retrograde pyelography localizing the site of obstruction demonstrate the extent of the obstructed segment anatomic changes functional changes
Clinical findings 4.Special Examination Instrumental calibration of sites of obstruction is also valuable radioisotope renography ultrasonic examination shows hydronephrosis and residual urine Urine flow rate CT
Treatment 1. Relief of obstruction -BPH or obstructing bladder tumors require surgical removal -impacted stones must be removed
Treatment 2.urethral stricture can be dilatated or urethrotomy or urethroplasty