Hematuria and obstructive uropathy

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Pramongkutklao college of medicine

Pramongkutklao college of medicine

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  • 1. Hematuria & obstructive Uropathy
  • 2. Hematuria
  • 3. Physical Examination of Urine
    an evaluation of color, turbidity, specific gravity and osmolality, and pH.
  • 4.
  • 5. Urinary dipstick
    • Most common screening test for hematuria
    • 6. The reagent strip that detects blood utilizes hydrogen peroxide, which catalyzes a chemical reaction between hemoglobin (or myoglobin) and the chromogentetramethylbenzidine
    • 7. Different shades of blue-green are produced according to the concentration of hemoglobin in the urine
  • 8. Centrifuged urine
  • 9. 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.
  • 10. 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.
  • 11. 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.
  • 12. How to evaluate hematuria?
    By asking question
    • Is the hematuria gross or microscopic?
    • 13. At what time during urination does the hematuria occur (beginning or end of stream or during entire stream)?
    • 14. Is the hematuria associated with pain?
    • 15. Is the patient passing clots?
    • 16. 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
  • 17. Total Hematuria
    Terminal Hematuria
    Initial Hematuria
  • 18. Pain
    • Painful hematuria
    • 19. Painful micturition
    • 20. inflammation of the bladder or prostate.
    • 21. Colicky groin pain
    • 22. ureteral calculus.
    • 23. Burning pain in the penis or urethral opening in women
    • 24. urinary infection.
    • 25. Pain in the perineum associated with dysuria, fever, and rigors
    • 26. seen in prostatitis.
    • 27. Constant dull flank pain
    • 28. sign of advanced RCC
  • Classification : Pain
    Painless (Gross) Hematuria
    With Age > 50 years ( Mostly Men ) is HALLMARK for bladder cancer.
  • 29. Clots
    The presence of clots usually indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.
  • 30. Shape of Clots
    • Amorphous clots : bladder or prostatic urethral origin
    • 31. 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
  • 32. Causes of Hematuria
  • Most common cause of hematuria
    • 0-20 yr Acute glomerulonephritis
    Acute UTI
    Congenital UT anomalies with obstruction
    • 20-40 yr Acute UTI
    Stones
    Bladder tumors
    • 40-60 yr (men) Bladder tumors
    Acute UTI
    Stones
    • 40-60 yr (women) Acute UTI
    Stones
    Bladder tumors
    • 60 yr (men) BPH
    Bladder tumors
    Acute UTI
    • 60 yr (women) Bladder Tumor
    Acute UTI
  • 42.
  • 43.
  • 44. Glomerular Hematuria
    • Begin with a thorough history
    • 45. IgA nephropathy (Berger's disease)
    • 46. Familial nephritis or Alport's syndrome
    • 47. Goodpasture's syndrome
    • 48. Systemic Lupus erythematosus
    • 49. Poststreptococcalglomerulonephritis
  • 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
  • 50. Non-glomerular Hematuria
    Characterized by circular erythrocytes and the absence of erythrocyte casts
  • 51. An algorithm for the evaluation of nonglomerular hematuria
  • 52. Work –up : Laboratory Studies
    • Urinalysis
    • 53. Phase contrast microscopy
    • 54. BUN/serum creatinine: Elevated levels of BUN and creatinine suggest significant renal disease as the cause of hematuria
    • 55. Hematologic and coagulation studies: CBC counts , Platelet counts
    • 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. Serologic testing
    • 58. 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
    • 59. Urinary tract anomalies, such as hydronephrosis, hydroureter, nephrocalcinosis, tumor, and urolithiasis, are readily revealed with ultrasonography
    • 60. Compared with other imaging studies, sonography is rapid, noninvasive, readily available, and devoid of exposure to radiation
    • 61. 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
    • 62. A spiral CT scan is particularly useful in the detection of urolithiasis, Wilms tumor, and polycystic kidney disease
    • 63. Voiding cystourethrograms are valuable in detecting urethral and bladder abnormalities that may result in hematuria (eg, cystitis)
    • 64. 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
  • 65. Persistent microscopic Hematuria
    Evidence of glomerular disease
    Yes
    No
    Renal parenchymal disease evaluation
    Urologic evaluation
    Renal Biopsy
    Risk of urologic malignancy
    • Age > 40 years
    • 66. Heavy smoking
    • 67. Pelvic radiation
    • 68. Exposure: dyes benzene
    • 69. Chronic urological tract infection
    - Urine 24-hr, calcium
    - Imaging
    - Cystoscopy + Cytology
    No
    - Imaging
    - Cystoscopy + Cytology
    Yes
  • 70. Obstructive Uropathy
  • 71. Definition
    Functional or anatomic obstruction of
    urinary flow at any level of the urinary
    tract
  • 72. Classification
    Obstructive uropathy may be classified in to
    • congenital/acquired
    • 73. Benign/malignant
    • 74. Partial/complete
    • 75. Unilateral/bilateral
    • 76. Acute/Chronic
  • Etiology
    Congenital
    • meatalstenosis
    • 77. ureteral strictures
    • 78. posterior urethral strictures
    • 79. ureterovesical junction obstruction
    ureteropelvic junction obstruction
    (various causes)
    • neurologic deficites
    Acquired
    • urethral strictures inflammatory
    or traumatic
    • bladder outlet obstruction
    • 80. vesical tumor
    • 81. neurogenic bladder
    • 82. extrinsic ureteral compression
    • 83. 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
  • 84. 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
  • 85. Physical Exam: Present Illness
    Signs
    Lower urinary tract
    -Palpation of urethra
    -Vesical distention
  • 86. Physical Exam: Present Illness
    2. Upper urinary tract
    -Palpation of kidney
  • 87. Pathogenesis (pathophysiology)
    The changes in the various segments in the urinary tract, depending on the obstructive severity and duration
    1. Urethral changes: dilatation, diverticulum
  • 88. 2. Bladder changes: trabeculation , trigone hypertrophy , diverticulum
  • 89. 3. Ureteral changes: distention, dilatation and hydroureter
  • 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.
    5. Renal Parenchymal Changes : compression, ischemic atrophy.
  • 91.
  • 92. 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
  • 93. Clinical findings
    2.Laboratory findings
    Urinalysis
    BUN
    Creatinine
    Impaired kidney function
    elevated blood urea nitrogen
    and serum creatinine
  • 94. 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
  • 95. 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
  • 96. Treatment
    1. Relief of obstruction
    -BPH or obstructing bladder tumors require surgical removal
    -impacted stones must be removed
  • 97. Treatment
    2.urethral stricture can be dilatated or urethrotomy or urethroplasty
  • 98. Treatment
    3.Percutaneous nephrostomy or double –J stent
    4.GFR< 10% : nephrectomy
  • 99. Thank You