GEMC: Evaluation of Hematuria

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This is a lecture from the Ghana Emergency Medicine Collaborative (GEMC). To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc.

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GEMC: Evaluation of Hematuria

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Evaluation of Hematuria Author(s): Rodney Smith (University of Michigan), MD. 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1  
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. 2   To use this content you should do your own independent analysis to determine whether or not your use will be Fair.
  3. 3. Evalua)on  of  Hematuria   Rodney  Smith,  MD   University  of  Michigan  Department  of   Emergency  Medicine   St.  Joseph  Mercy  Hospital   3  
  4. 4. Objec)ves   •  Describe  the  evalua)on  and  management  of   gross  hematuria   •  Describe  the  evalua)on  and  management  of   microscopic  hematuria   4  
  5. 5. Case  Presenta)on   •  34  year  old  female  presents  with  depression   and  suicidal  idea)on   –  Recent  divorce,  not  sleeping  well   –  Otherwise  healthy   –  Normal  physical  exam   –  CBC,  Basic,  UDS  all  normal   5  
  6. 6. Case  Presenta)on   •  Urinalysis   –  Normal  except   •  1+  blood   •  Tr  protein   •  2  WBC   •  12  RBC   •  2  epi   •  No  bacteria   6  
  7. 7. •  Is  this  pa)ent  medically  cleared  for  psych   admission?   •  What  further  evalua)on  is  necessary   7  
  8. 8. Does  this  pa)ent  have  hematuria?   •  Hematuria   •  >2-­‐3  RBCs  per  HPF   •  Microscopic  hematuria   –  Yellow  urine   –  Concentra)on   •  Gross  hematuria   –  Red/brown  urine   –  1  ml  blood     –  Presence  of  clots  =  post  glomerular  disease     8  
  9. 9. Does  this  pa)ent  have  hematuria?   Centrifuge  Result   Sediment  Red   Hematuria   Supernatant  Red   Nega%ve   Dips)ck  H=heme   Beeturia   Phenazopyridine   Porphyria   Posi%ve   Myoglobin   Hemoglobin   Clear   Myoglobinuria   Plasma  Color   Red   Hemoglobinuria   9  
  10. 10. Evalua)on  of  hematuria   •  Clues  from  history  and  physical   •  Glomerular  vs.  Extraglomerular   •  Transient  vs.  Persistent   10  
  11. 11. History     •  Infec)on  symptoms?   –  Cys))s:  dysuria,  frequency   –  Pyelonephri)s:  flank  pain,  fever   –  Recent  URI?   •  Flank  pain,  especially  unilateral   –  Stone   –  Blood  clot   –  Malignancy   11  
  12. 12. History   •  Symptoms  of  prosta)c  obstruc)on   –  BPH   –  Malignancy   •  Coagulopathy   –  Therapeu)c  range   –  Culclaure  TF  Arch  Intern  Med  1994   •  Rate  of  hematuria  in  treated  and  controls  equal   •  81%  with  hematuria  had  iden)fiable  cause   12  
  13. 13. History   •  Rela)onship  with  menstrua)on   –  Endometriosis   –  Contamina)on   •  Collec)on  of  urine  specimen   •  Sickle  cell  disease/trait   •  Hereditary  disorders   –  Polycys)c  kidney  disease   –  Hereditary  nephri)s   13  
  14. 14. Glomerular  vs.  Extraglomerular     •  Urinalyis   –  Red  cell  casts   –  Proteinuria   •  >  1+   •  Not  seen  in  gross  hematuria   –  Red  cell  morphology   •  Deformed  as  they  pass  thru  basement  membrane   •  Osmo)c  injury  in  nephron   –  Urine  color   •  Smoky  brown  =  methemoglobin   –  Blood  clots   14  
  15. 15. Transient  vs.  Persistent   •  Transient  usually  benign   –  Infec)on   –  Stones   –  Exercise   •  May  be  seen  in  pa)ents  with  malignancy   15  
  16. 16. Risk-­‐factors  for  Malignancy   •  Age  >  40   •  Smoking  history   •  Occupa)onal  exposures   –  Printers,  painters,  chemical  plant  workers   •  •  •  •  Gross  hematuria   Chronic  irrita)ve  voiding  symptoms   History  of  pelvic  irradia)on   Analgesic  abuse   16  
  17. 17. Case  1   •  22  yo  female     –  2  days  of  dysuria,  frequency,  urgency   –  Now  with  hematuria   –  No  fever,  no  flank  pain   –  LMP  2  weeks  ago,  not  sexually  ac)ve   –  Normal  VS   –  Suprapubic  tenderness  on  exam   17  
  18. 18. Case  1   •  Further  evalua)on?   18  
  19. 19. Case  1   •  Over  the  counter  meds?   •  Urinalysis   –  Bloody  urine   –  1+  Leukocyte  esterase   –  >  100  WBC   –  >  100  RBC   –  2+  bacteria   19  
  20. 20. Urinary  Tract  Infec)on   •  Does  this  pa)ent  need  a  urine  culture?   20  
  21. 21. Urinary  Tract  Infec)on   •  Urine  culture  in   –  Relapse   –  Suspicion  for  pyelonephri)s   •  Flank  pain   •  Fever   •  Treatment   –  Phenazopyridine   –  An)bio)cs   •  3  days   •  7  days   21  
  22. 22. Case  2   •  43  yo  male,  previously  healthy   •  Gross  hematuria  2  days  ago   •  Acute  onset  of  severe  right  flank  pain   –  Radiates  to  groin   –  Diaphoresis,  nausea,  emesis  X  1   –  Can’t  find  comfortable  posi)on   –  Mild  right  CVA  tenderness   22  
  23. 23. Case  2   •  Ini)al  treatment?   23  
  24. 24. Case  2   •  Ini)al  treatment   –  IV  toradol,  an)-­‐eme)cs,  narco)cs  prn   –  Urinalysis   •  1+  blood   •  12  RBC   •  No  WBC,  bacteria   –  IV  fluid  bolus?   24  
  25. 25. Renal  Colic   •  Passage  of  stone  from  kidney  to  bladder   •  Localiza)on  of  pain  oken  related  to  site  of  stone   –  Lower  ureter/UVJ  groin   •  •  •  •  Family  history   Recurrence   Concomitant  infec)on   Mimics   –  AAA   –  Ectopic  pregnancy     25  
  26. 26. Renal  Colic   •  Non-­‐contrast  CT   –  Sensi)vity  95%   –  Specificity  99-­‐100%   –  Other  diagnosis   –  Use  with  KUB   •  USN   –  Obstruc)on   –  In  ability  to  give  contrast   –  Recurrent  stone   26  
  27. 27. Renal  Colic   •  •  •  •  •  NSAIDs   Narco)cs   Calcium  channel  blocker   Alpha  blocker   Size  and  loca)on   27  
  28. 28. Case  3   •  73  yo  male   –  Gross  hematuria  for  2  days   –  Unable  to  void  for  past  8  hours   –  Mildly  hypertensive   –  Obvious  distress   –  Bladder  disten)on  on  physical  exam   –  Foley  catheter   •  Bloody  urine   •  Blood  clots   28  
  29. 29. Case  3   •  Next  steps?   29  
  30. 30. Case  3   •  •  •  •  •  CBC   Basic   Coumadin:  INR   Urinalysis,  Urine  culture   Bladder  irriga)on   30  
  31. 31. Gross  Hematuria   •  •  •  •  Infec)on  25%   Stone  20%   VS  seldom  unstable   Assure  urinary  drainage   –  History  of  blood  clots   –  Size  of  clots   –  Ease  of  passage  of  urine   31  
  32. 32. Gross  Hematuria   •  Clot  reten)on   –  Foley  catheter   •  16  F  or  larger   •  Three-­‐way  catheter   •  Discharge  with  catheter  vs.  removal   •  Followup   32  
  33. 33. Case  4   •  •  •  •  31  yo  male   Completed  first  marathon     Blood  in  urine   U/A   –  Red  urine   –  >150  RBC   –  No  WBC,  bacteria,  protein   33  
  34. 34. Exercise-­‐induced  Hematuria   •  Contact  sports   •  Non-­‐contact  sports   –  Long-­‐distance  running   •  10-­‐20%   –  Rowing   –  Swimming   –  Cycling   34  
  35. 35. Exercise-­‐induced  Hematuria   •  Mechanism   –  Increased  urinary  excre)on   –  Long-­‐distance  running/cycling   •  Bladder  trauma   –  Bicycling   •  Urethra  trauma   –  ?  Renal  ischemia   –  Nutcracker  syndrome   35  
  36. 36. Exercise-­‐induced  Hematuria   •  Rule-­‐out  myoglobinuria   •  Followup   –  Clears  within  one  week   –  Consider  full  workup  with  risk  factors  for   malignancy   36  
  37. 37. Case  5   •  34  yo  female  with  1  week  of  progressive   swelling  in  the  lower  extremi)es   •  No  chest  pain,  dyspnea,  orthopnea,   abdominal  pain  or  disten)on   •  VS  148/92    88    14    98.3    99%   •  Exam  normal  except  for  2+  pre-­‐)bial  pimng   edema   37  
  38. 38. Case  5   •  CBC  normal   •  Basic  normal  except  BUN  24  Creat  1.42   •  U/A   –  3+  protein   –  12  RBCs   –  No  WBCs,  bacteria   38  
  39. 39. Glomerulonephropathy   •  ED  care  is  usually  suppor)ve   –  Treat  hypertension  if  emergency/urgency   –  Close  followup   –  Admission  criteria   •  Acute  renal  failure   •  Hypertensive  emergency/urgency   •  Oliguria/anuria   •  Electrolyte  abnormali)es   •  CHF/volume  overload   39  

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