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Heamaturia 2

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lecture by Dr. Ahmed Rehman

lecture by Dr. Ahmed Rehman

Published in Health & Medicine
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  • 1. Haematuria Causes And Workup
  • 2. Learning Objectives
    • To be able to enumerate causes of hematuria
    • To be able take elaborate history and conduct relevant clinical examination
    • To be able to make a diagnosis.
    • To be able to suggest and interpret relevant investigations
  • 3. Hematuria
    • Gross blood in urine
    • Microscopic 3 to 5 RBCs per HPF
    • Always abnormal = whether macro, micro, single episode or patient on anticoagulants
  • 4.
    • Terminal : proximal urethra, baldder neck/trigone, Iniial: distal to ext sphincter, total baldder / upper tract ( basis of 3 glass test)
    • History & exam not sufficent to make diagnosis, so always needs investigations.
    • Degree bears no relation with severity of disease. Always take it serious until proved otherwise.
  • 5. Surgical Causes
    • Kidneys
      • Congenital – polycystic, PUJ, medullary sponge kidney
      • Trauma – stone, rupture, runner’s hematuria
      • Inflammation – Nonspecific, TB,
      • Neoplastic – RCC, TCC pelvis, Wilm’s
      • papillary necrosis
      • Vascular / Congestion – AV malformations, RHF,renal vein thrombosis,
      • Infarction – arterial thrombosis / embolism
      • Glomerular disorders – glomerulonephritis, IgA nephropathy, Benign idiopathic hematuria
      • Lymphoma, multiple myeloma, amiloidosiss
  • 6. Surgical Causes
      • Ureters
        • Stones, TCC ureter, VUR, stricture,
    • Bladder
      • Trauma, stone, catheter trauma
      • Inflammation – cystitis, TB, Bilharzia, post-radiation cystitis, cyclophosphamide chemo.
      • Neoplastic – TCC, adeno squaamous
    • Prostate
      • BPH, CaP, prostititis,
  • 7. Surgical Causes
    • Urethra
      • Trauma, rupture, stone, catheter trauma
      • Inflmmation – urethritis
      • Neoplaastic – TCC urethra, penile Ca
      • Atrophic urethritis
  • 8. Surgical Causes
    • Miscellaneous
      • Endometriosis
      • Diverticulitis
      • Appendicitis
      • Abdominal aortic aneurysm
      • Foreign body
  • 9. Surgical Causes
    • False hematuria food colors / drugs staining red (beet roots, Dindevan, pyridium,furadantin, rifampicin,= differentiation made with microscopy (RBCs)
    • False +ve dipstick test.hemoblobin, erthrocytes, myoblobin, pigmenturia. DD= microscopy
    • Factitious = source outside urinary system
      • Vaginal bleeding, malingering
  • 10. Medical Causes
    • Systemic disorders
      • Haematological
        • Bleeding disorders
          • purpura, sickle cell disease, hemophilia, scurvy
        • therapeutic anticoagulants,
    • Malaria, SLE, Henoch Schonlein purpura, hypersensitivity angiitis, bacterial endocarditis, Wegener’s granulomatosis, Good pastures Syndrome
  • 11. Points in history
    • Pain – renal, ureteric stone, clot, cysts, hydronephrosis, adv. Tumors, trauma
    • Trauma, wt. loss, LUTS, dysuria, fever, riger, constitutional symptoms
    • Pattern of hematuria- gross, micro, partial, total, persistant/continuous, intermittent,
    • Clots long threadlike, amorphous, fresh, old
    • Smoking, occupaton, travel to schist areas,
    • Rash, joint paain (SLE)
    • URTI-PSGN
    • Purpura, rash, echymosis, easy bruiseability, bleed from multiple sites
    • Medication – color, anticoagulants
    • Exercise, sepsis, systemic diseases = liver, renal failue
    • Mass, TB
  • 12. Clinical examination
    • No physical sign / Anything could be found
    • Disoriented – liver / renal failue
    • Catheter / irrigation / drip / canulla
    • Pain agony – stone, HN, retention
    • Cechhexia,
    • Pulse shock, sepsis
    • BP , normal, shock, high ( HTN, renal failure)
    • Temp infection
    • Resp renal failure, acidosis
    • Purpura, rash, echymosis
    • Pallor / degree, anemia hematuria, renal failure
    • Jaundice, edema, L.nodes
    • Palpable visreras, L,S,K,K,UB,LN, masses,
    • prostate, urethra, testes, epid- vas (TB), meatus,stricure, retention
  • 13. Workup
    • Esteblish hematuria - dipstick
    • Urine RE/microsscopy-RBCs
    • Urine CS – infection, doesn’t rule out other causes
  • 14. Imaging: US
    • cheap, easy, easily available, noninvasive, no countraindication, nontoxic, no side eff/reaction
    • Kidney: size, echogenicity, cortical thickness, cysts, mass, hydronephrosis, stone, C/m ratio
    • Ureter: dilated, stonne, mass, ureterocele
    • Blaadder: stone, wall thickness / smooth, mass, clot, diverticula, capacity, pre- postvvoid vlo
    • Prostste size, echogenicity
  • 15. Disadvantages US
    • : good for renal parenchyma but not for pelvicaliceal system, ureter annd not very good for bladder – mas miss lesions. Observer dependant, inter and intraobserver variability
  • 16. IVU
    • Conventional
    • Invasive ( IV contrast, side eff/ adverse eff – anaphylaxis, toxicity,- drug, radiation)
    • May not be diagnostic
    • Demonstrates anatomy –normal / cong abormalities and function – secretion thru kidney, transport thru collecting system, storage in bladder and evacuation.
    • Very good for pelvicaliceal system and ureter
    • ROS, filling defect, (mass, Radiolucent stone, clot, fungus, FB
    • Many would proceed to cystoscopy after USG leaving IVU
  • 17. IVU
    • Principle
    • Indications
      • Stone, hematuria, trauma, congenital abnormalities, mass, assessment of function, obstruction
    • Preparation
      • Purgation, hydration
    • Precautions
      • Not during pain, renal status, hydration, clear KUB, allergy
    • Procedure
      • Test dose, procedure – timings
    • Side / adverse reactions – management of
    • Contra-indications
    • Interpretation
    • Disadvantages
    • Constrast and other things required
  • 18. Cystoscopy
    • Visualizes lower tract starting at ext meatus, leading to bladder.( U, P, BN, )
    • bladder
      • capacity, bleeding site, edema/ congestion,ulcer, mass, granuloma, orifices, diverticula, trabeculations, stone,
    • Biopsy, brushings cytology,
    • Retrograde uro/pyelography / uretero-renoscopy
    • USG+cystoscopy +/_ RPG ay obviate need for IVU in most but not all cases, in which case a formal IVU or a constrast CT scan is required
  • 19. Urinary cytology, flow cytometery, tumour markers-NMP22, BTA
    • May be helpful, being noninvasive, but not established to a point to replace routine workup.
    • Yield varies from study to study & grade and type lesion
  • 20. Hematuria of obscure origin
    • 20%
    • Just explain that investigations that are usually carried oout have not demonstrated any cause -
    • Do reassure but Never explain that all is OK, a future investigation may show some cause in evolution or appearing then
    • Follow up is required
    • Emmergency cystoscope in cases of active rebleed