Slide of hematuria and its approach

1. HEMATURIA
PRESENTER: DR ANAND UJJWAL SINGH ( JR2)
MODERATOR: DR RIKESH JUNG KARKEE

2. Sequence of flow:
• Origin
• Anatomy and Blood supply
• Glomerular filtration and Glomerular filtration barrier (GFB)
• Factors associated with pathogenic process
• Types
• Etiology / Differential diagnosis
• Evaluation
• Goals for treatment
• Special conditions

3. ORIGIN:
• hemato- [G. haima (haimat-)]+ G. ouron, urine

4. ANATOMY AND BLOOD SUPPLY:
Bailey and Love’s Essential Clinical
Anatomy

5. • Vertically: Upper border of T12 vertebra to centre of body of L3 vertrebra
• Right kidney is slightly lower than left
• Left kidney is slightly nearer to the median plane
• Kidney (Renal) angle: angle between the 12th rib and outer border of
sacrospinalis.
Bailey and Love’s Essential Clinical
Anatomy

6. BLOOD SUPPLY:

7. GLOMERULAR FILTRATION:

8. GFB (GLOMERULAR FILTRATION BARRIER) has five major components:
(1) from the vascular side, the endothelial surface layer, a complex
glycosaminoglycan net which cover the endothelial layer as well as the
fenestrations
(2) the endothelial cell
(3) the GBM
(4) podocytes with its interdigitating foot processes and specialized intercellular
junctions, the “slit diaphragms”
(5) finally on the urinary side, the subpodocyte space, an area delimited between
the podocyte cell body and the foot processes
Yuste et al. World J Nephrol. 2015

9. • endothelium fenestrations (50-100 nm) acts as molecular size sieve,
self-sufficient to maintain the RBCs (6.2-8.2 μm) away from the GBM.

10. Factors associated with pathogenic process:
(1) genetic alteration of GFB components, leading to a more fragile and
easily ruptured GFB structure
(2) aberrant deposition of toxic molecules in the GFB
(3) enhanced inflammatory response, as reported in autoimmune
diseases, infections, or primary glomerulonephritis.
Yuste et al. World J Nephrol. 2015

11. Yuste et al. World J Nephrol. 2015

12. • Hematuria is defined as the presence of 5 or more red blood cells
(RBCs) per high-power field in 3 of 3 consecutive centrifuged
specimens obtained atleast 1 week apart.

13. Types:
According to the amount of RBC in the urine, hematuria can be
classified as:
Gross: (ie. overtly bloody, smoky, or tea-colored urine)
Microscopic: > 5 RBCs /HPF

14. According to Timing (when it occurs during urination):
Early (initial) hematuria: Urethral origin, distal to external sphincter
Terminal hematuria: Bladder neck or prostate origin
Diffuse (total) hematuria: Source is in the bladder or upper urinary
tract

15. • False hematuria: Discolouration of urine from pigments such as food
colouring and myoglobin.
• Silent hematuria is due to tumours of kidney or bladder unless
proved otherwise.

16. • According to Pathology:
• Glomerular
• Non Glomerular

17. HEMATURIA GLOMERULAR NON- GLOMERULAR
SIZE Irregular Uniform
SHAPE Small Larger
SOURCE Nephron Peripheral

19. Painful and Painless Hematuria:
Painful hematuria
Painful micturition:
inflammation of the bladder or prostate
Colicky groin pain:
ureteric calculus
Burning pain in the penis or urethral opening in women:
urinary infection

20. Pain in the perineum associated with dysuria, fever, and rigors:
prostatitis
Constant dull flank pain:
sign of advanced RCC

21. • Painless (Gross) Hematuria
With Age > 50 years ( Mostly Men ) is HALLMARK for bladder cancer.

22. Duration of Hematuria:
Transient Hematuria:
• Benign & without any obvious etiology in 39%of young adults
• 8-9% of adults >50y/o – malignancy

23. 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

24. Clots:
• indicates a more significant degree of hematuria
• probability of identifying significant urologic pathology increases.

25. • Amorphous clots : bladder or prostatic urethral origin
• Vermiform (wormlike) clots, particularly if associated with flank pain :
the upper urinary tract : ureter

26. ETIOLOGY / DIFFERENTIAL DIAGNOSIS

27. Macroscopic hematuria:
• Urinary tract malignancy: kidney, renal pelvis, ureter, bladder, prostate,
urethra
• Urinary calculi
• Infections: urinary tract infection, schistosomiasis
• Trauma: penetrating or blunt
• Benign prostatic hyperplasia
• Haemorrhagic cystitis Emerg Med J. 2007, Management of
macroscopic haematuria in the
emergency department
, Hicks et al

28. • Endometriosis
• Nephrological disease: IgA nephropathy, glomerulonephritis
• Postprocedural bleeding—for example, transurethral surgery
• Bleeding disorders, anticoagulation therapy above therapeutic range
• Arteriovenous malformation/angiomyolipoma
Emerg Med J. 2007, Management of
macroscopic haematuria in the
emergency department
, Hicks et al

29. Glomerular Hematuria:

31. Algorithm for evaluation of Nonglomerular hematuria:

32. Associated symptoms to be elicited:
• ability to pass urine and evidence of clots
• fever, urgency and urinary incontinence

33. Predisposing factors that should be sought in the history:
• Occupational history—in particular, exposure to chemicals and smoking, as
these predispose to risks of transitional cell carcinoma of the bladder.
• History of bleeding disorders or concomitant use of anticoagulants may
prompt investigation with clotting profile.
• History of trauma is important, as this dictates a different diagnostic
approach and may be a contraindication to urinary catheterisation.

34. • History of recent sore throat/upper respiratory tract infection in
young patients may be suggestive of IgA nephropathy.
• Travel history, as schistosomiasis is a risk factor for squamous cell
carcinoma of the bladder and in itself causes macroscopic
haematuria.

35. Clinical examination:
• Cardiovascular status.
• Presence of a palpable bladder, which may be indicative of acute or
imminent urinary retention.
• Careful palpation for a tumour mass (potential sites include renal,
bladder or gynaecological origin).

36. • Females: a vaginal examination should be performed to ensure that
the blood comes from the urethra rather than the vagina.
• Males: the external genitalia should be examined.
• digital rectal examination (DRE)

37. Workup : Laboratory Studies
• Urinalysis
• Phase contrast microscopy
• BUN/serum creatinine: Elevated levels of BUN and creatinine suggest
significant renal disease as the cause of hematuria
• Hematologic and coagulation studies: CBC counts, Platelet counts

38. • 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.
• Serologic testing
• Urine culture : A midstream or clean-catch specimen of urine should
be obtained for culture sensitivity whenever a urinary tract infection
is suspected.

39. • Microscopy of urinary sediment:
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

40. A cast containing numerous
erythrocytes, indicating
glomerulonephritis

41. Workup : Imaging studies
• Renal and bladder ultrasonography:
Urinary tract anomalies, such as hydronephrosis, hydroureter,
nephrocalcinosis, tumor, and urolithiasis, are readily revealed rapid,
noninvasive, readily available, and devoid of exposure to radiation

42. • Spiral CT scan:
particularly useful in the detection of urolithiasis, Wilms tumor, and
polycystic kidney disease.
• Voiding cystourethrograms:
detecting urethral and bladder abnormalities that may result in hematuria
(eg, cystitis)
• Radionuclide studies

45. Goals for treatment of macroscopic haematuria:
• R–resuscitate as appropriate
• E–ensure that urine can drain freely with or without catheter
insertion
• S–safe discharge from the ED where appropriate
• P–prompt follow‐up and further investigation
Emerg Med J. 2007, Management of
macroscopic haematuria in the
emergency department
, Hicks et al

46. Indications for seeking further medical attention:
• Darkening of the haematuria that does not clear after a few voidings,
despite adequate fluid intake.
• Increasing clot formation that does not clear easily on voiding, or
development of urinary retention.
• Worsening pain or fever, despite using analgesics or antibiotics.

47. Wunderlich syndrome:
• spontaneous, nontraumatic bleeding, confined to the subcapsular
and perirenal space
• first manifestation of a renal angiomyolipoma (AML), or rupture
of renal artery or intraparenchymal aneurysm

48. RENAL TUBERCULOSIS:
• Preferred place for colonization : Medullary region, granulomatous lesion
with caseous necrosis  local tissue destruction
• Bacilli migrate to cortico-medullary junction  cortical granulomas
• Reactivates and invades renal medulla  papillitis  papillary necrosis
(due to vascular insufficiency)
• Formation of cavities  destruction of renal parenchyma  migration to
collecting system
Renal Tuberculosis in the Modern Era, Am
J Trop Med Hyg. 2013, Daher et al

49. • Dissemination of infection to renal pelvis  tuberculous
pyelonephritis  pyonephrosis
• Dissemination from ureter to bladder  granulomatous lesion with
fibrosis
Renal Tuberculosis in the Modern Era, Am
J Trop Med Hyg. 2013, Daher et al