Hematuria and obstructive uropathy

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Hematuria and obstructive uropathy

  1. 1. Hematuria & obstructive Uropathy<br />
  2. 2. Hematuria<br />
  3. 3. Physical Examination of Urine<br />an evaluation of color, turbidity, specific gravity and osmolality, and pH.<br />
  4. 4.
  5. 5. Urinary dipstick<br /><ul><li>Most common screening test for hematuria
  6. 6. The reagent strip that detects blood utilizes hydrogen peroxide, which catalyzes a chemical reaction between hemoglobin (or myoglobin) and the chromogentetramethylbenzidine
  7. 7. Different shades of blue-green are produced according to the concentration of hemoglobin in the urine </li></li></ul><li>
  8. 8. Centrifuged urine<br />
  9. 9. Centrifuged urine<br />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. <br />
  10. 10. Centrifuged urine<br />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.<br />
  11. 11. Quantity of Hematuria<br />Microscopic Hematuria : <br /> seen only under microscope<br />Gross Hematuria : <br /> visible, urine is pink, cola, red<br />5 times the number of life-threatening conditions when compared with patients with microscopic hematuria.<br />
  12. 12. How to evaluate hematuria?<br />By asking question<br /><ul><li>Is the hematuria gross or microscopic?
  13. 13. At what time during urination does the hematuria occur (beginning or end of stream or during entire stream)?
  14. 14. Is the hematuria associated with pain?
  15. 15. Is the patient passing clots?
  16. 16. If the patient is passing clots, do the clots have a specific shape? </li></li></ul><li>Timing of Hematuria<br />Frequently indicating the site of origin as<br />Initial hematuria<br /> from urethra, least common, usually secondary to inflammation<br />Terminal hematuria<br /> secondary to inflammation at bladder neck or prostatic urethra<br />Total hematuria<br /> from bladder or upper tract, most common<br />
  17. 17. Total Hematuria<br />Terminal Hematuria<br />Initial Hematuria<br />
  18. 18. Pain<br /><ul><li>Painful hematuria
  19. 19. Painful micturition
  20. 20. inflammation of the bladder or prostate.
  21. 21. Colicky groin pain
  22. 22. ureteral calculus.
  23. 23. Burning pain in the penis or urethral opening in women
  24. 24. urinary infection.
  25. 25. Pain in the perineum associated with dysuria, fever, and rigors
  26. 26. seen in prostatitis.
  27. 27. Constant dull flank pain
  28. 28. sign of advanced RCC</li></li></ul><li>Classification : Pain<br />Painless (Gross) Hematuria<br />With Age > 50 years ( Mostly Men ) is HALLMARK for bladder cancer.<br />
  29. 29. Clots<br />The presence of clots usually indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.<br />
  30. 30. Shape of Clots<br /><ul><li>Amorphous clots : bladder or prostatic urethral origin
  31. 31. Vermiform (wormlike) clots, particularly if associated with flank pain : the upper urinary tract : ureter</li></li></ul><li>Duration of Hematuria<br />Transient Hematuria<br />Benign & without any obvious etiology in 39%of young adults <br />8-9% of adults >50y/o – malignancy<br />Persistent Hematuria<br />Defined as three positive urinalyses, based on a test strip and microscopic examination, over a 2- to 3- week period<br />Microscopic – 5% malignancy<br />Macroscopic – 20% malignancy<br />
  32. 32. Causes of Hematuria<br /><ul><li>Congenital/inherited
  33. 33. PCKD, Hematologic abnormalities
  34. 34. Trauma
  35. 35. Neoplasm
  36. 36. Benign or malignant
  37. 37. Infection/Inflammation
  38. 38. Metabolic
  39. 39. Stone
  40. 40. Miscellaneous
  41. 41. Drug</li></li></ul><li>Most common cause of hematuria <br /><ul><li>0-20 yr Acute glomerulonephritis</li></ul> Acute UTI<br /> Congenital UT anomalies with obstruction <br /><ul><li>20-40 yr Acute UTI</li></ul> Stones<br /> Bladder tumors<br /><ul><li>40-60 yr (men) Bladder tumors</li></ul> Acute UTI<br /> Stones<br /><ul><li>40-60 yr (women) Acute UTI</li></ul> Stones<br /> Bladder tumors<br /><ul><li>60 yr (men) BPH</li></ul> Bladder tumors<br /> Acute UTI<br /><ul><li>60 yr (women) Bladder Tumor</li></ul> Acute UTI<br />
  42. 42.
  43. 43.
  44. 44. Glomerular Hematuria<br /><ul><li>Begin with a thorough history
  45. 45. IgA nephropathy (Berger's disease)
  46. 46. Familial nephritis or Alport's syndrome
  47. 47. Goodpasture's syndrome
  48. 48. Systemic Lupus erythematosus
  49. 49. Poststreptococcalglomerulonephritis</li></li></ul><li>Non-glomerular Hematuria <br />Non-glomerular hematuria or essential hematuria includes primarily urologic rather than nephrologic diseases<br />Common causes of essential hematuria include urologic tumors, stones, and UTIs<br />
  50. 50. Non-glomerular Hematuria <br />Characterized by circular erythrocytes and the absence of erythrocyte casts<br />
  51. 51. An algorithm for the evaluation of nonglomerular hematuria<br />
  52. 52. Work –up : Laboratory Studies<br /><ul><li>Urinalysis
  53. 53. Phase contrast microscopy
  54. 54. BUN/serum creatinine: Elevated levels of BUN and creatinine suggest significant renal disease as the cause of hematuria
  55. 55. Hematologic and coagulation studies: CBC counts , Platelet counts
  56. 56. Urine calcium : A calcium excretion of more than 4 mg/kg/d or a urine calcium-creatinine ratio of more than 0.21 are considered abnormal.
  57. 57. Serologic testing
  58. 58. Urine culture : A midstream or clean-catch specimen of urine should be obtained for culture sensitivity whenever a urinary tract infection is suspected.</li></li></ul><li>Work-up : Imaging Studies<br /><ul><li>Renal and bladder ultrasonography
  59. 59. Urinary tract anomalies, such as hydronephrosis, hydroureter, nephrocalcinosis, tumor, and urolithiasis, are readily revealed with ultrasonography
  60. 60. Compared with other imaging studies, sonography is rapid, noninvasive, readily available, and devoid of exposure to radiation
  61. 61. In individuals with severe obesity, a more accurate definition of renal structures and surrounding organs can be achieved using only CT scanning</li></li></ul><li>Work-up : Imaging Studies<br /><ul><li>Other imaging studies
  62. 62. A spiral CT scan is particularly useful in the detection of urolithiasis, Wilms tumor, and polycystic kidney disease
  63. 63. Voiding cystourethrograms are valuable in detecting urethral and bladder abnormalities that may result in hematuria (eg, cystitis)
  64. 64. Radionuclide studies can be helpful in the evaluation of obstructing calculi </li></li></ul><li><ul><li>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</li></li></ul><li><ul><li>Microscopy of urinary sediment. A cast containing numerous erythrocytes, indicating glomerulonephritis</li></li></ul><li>
  65. 65. Persistent microscopic Hematuria<br />Evidence of glomerular disease<br />Yes<br />No<br />Renal parenchymal disease evaluation<br />Urologic evaluation<br />Renal Biopsy<br />Risk of urologic malignancy<br /><ul><li>Age > 40 years
  66. 66. Heavy smoking
  67. 67. Pelvic radiation
  68. 68. Exposure: dyes benzene
  69. 69. Chronic urological tract infection</li></ul>- Urine 24-hr, calcium<br />- Imaging<br />- Cystoscopy + Cytology<br />No<br />- Imaging<br />- Cystoscopy + Cytology<br />Yes<br />
  70. 70. Obstructive Uropathy<br />
  71. 71. Definition<br />Functional or anatomic obstruction of<br /> urinary flow at any level of the urinary<br /> tract<br />
  72. 72. Classification<br />Obstructive uropathy may be classified in to<br /><ul><li>congenital/acquired
  73. 73. Benign/malignant
  74. 74. Partial/complete
  75. 75. Unilateral/bilateral
  76. 76. Acute/Chronic</li></li></ul><li>Etiology<br />Congenital<br /><ul><li>meatalstenosis
  77. 77. ureteral strictures
  78. 78. posterior urethral strictures
  79. 79. ureterovesical junction obstruction</li></ul>ureteropelvic junction obstruction<br /> (various causes)<br /><ul><li>neurologic deficites</li></ul>Acquired<br /><ul><li>urethral strictures inflammatory</li></ul> or traumatic<br /><ul><li>bladder outlet obstruction
  80. 80. vesical tumor
  81. 81. neurogenic bladder
  82. 82. extrinsic ureteral compression
  83. 83. ureteral or pelvic stones, strictures and tumor</li></li></ul><li>History taking: Present Illness<br />Symptoms<br />Lower urinary tract (urethra and bladder)<br /> -hesitancy <br /> -lessened force and size of the stream<br /> -terminal dribbling<br />
  84. 84. History taking: Present Illness<br />2.Upper urinary tract ( ureter and kidney)<br /> -pain in the flank radiating along the course of <br /> the ureter<br /> -gross hematuria (from stone)<br /> -GI symptoms<br /> -fever with chills<br /> - may be asymptomatic <br />
  85. 85. Physical Exam: Present Illness<br />Signs<br />Lower urinary tract<br /> -Palpation of urethra<br /> -Vesical distention <br />
  86. 86. Physical Exam: Present Illness<br />2. Upper urinary tract<br /> -Palpation of kidney<br />
  87. 87. Pathogenesis (pathophysiology)<br /> The changes in the various segments in the urinary tract, depending on the obstructive severity and duration<br />1. Urethral changes: dilatation, diverticulum<br />
  88. 88. 2. Bladder changes: trabeculation , trigone hypertrophy , diverticulum<br />
  89. 89. 3. Ureteral changes: distention, dilatation and hydroureter<br />
  90. 90. 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.<br /> 5. Renal Parenchymal Changes : compression, ischemic atrophy.<br />
  91. 91.
  92. 92. Clinical findings<br />1.Symptoms and signs: <br />infravesical obstruction :difficulty of voiding,weak stream ,diminished flow rate,terminal dribbling,burning ,frequency.<br />Supravesical obstruction :renal pain or renal colic,if gradually--asymptomatic or enlarged kidney<br />
  93. 93. Clinical findings<br />2.Laboratory findings<br />Urinalysis<br />BUN <br />Creatinine<br />Impaired kidney function <br /> elevated blood urea nitrogen <br /> and serum creatinine<br />
  94. 94. Clinical findings<br />3.X-Ray findings , IVP, Cystoscopy , Retrograde pyelography<br />localizing the site of obstruction<br />demonstrate the extent of the obstructed segment<br />anatomic changes <br />functional changes <br />
  95. 95. Clinical findings<br />4.Special Examination<br /> Instrumental calibration of sites of obstruction is also valuable<br />radioisotope renography<br />ultrasonic examination shows hydronephrosis and residual urine <br />Urine flow rate<br />CT <br />
  96. 96. Treatment<br />1. Relief of obstruction<br /> -BPH or obstructing bladder tumors require surgical removal <br /> -impacted stones must be removed <br />
  97. 97. Treatment<br />2.urethral stricture can be dilatated or urethrotomy or urethroplasty <br />
  98. 98. Treatment<br />3.Percutaneous nephrostomy or double –J stent<br />4.GFR< 10% : nephrectomy<br />
  99. 99. Thank You<br />

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