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Approach to a patient with haematuria_015210.pptx
1. Approach to a patient with
haematuria
DR. ABDULLAH-AL-MAMUN
RESIDENT PHASE A,NEPHROLOGY
DHAKA MEDICAL COLLEGE HOSPITAL
2. HAEMATURIA
• Presence of blood or blood cells in the urine .
• Can result from bleeding at any site in the urinary tract ,from kidney to the tip
of the urethra.
3. CLASSIFICATION OF HAEMATURIA
Macroscopic Haematuria
• Blood is visible to the naked eye. Gross haematuria startles the patient and
presents early.
• The patient may not recognize blood and report discoloration(pink, smoky, cola,
or tea-like).
• Macroscopic haematuria always requires investigation (presenting complaint in
85% of bladder and 40% of renal tumours).
• Heavy bleeding with clot formation almost never occurs in glomerular disease.
4. CLASSIFICATION OF HAEMATURIA Contd….
Microscopic haematuria
Arbitrary >2 red cells/hpf ( ~ 10^7 red cells/24h). However, it is
usually a +ve dipstick, not a cell count that triggers investigation
(dipsticks detect 2 – 5 cells/hpf).
9. CAUSES OF ISOLATED MACROSCOPIC HAEMATURIA
• Stone
• Tumour
• Tuberculosis
• Prostatitis
• Coagulation disorders
• IgA nephropathy
• Trauma
• Inflammatory glomerular disease (GN)
10. CAUSES OF ISOLATED MICROSCOPIC HAEMATURIA
• IgA Nephropathy
• Thin GBM disease
• Alport syndrome
• Renal cyst e.g. PKD
• Renal stone
• Loin pain haematuria syndrome
• Insignificant vascular malformation
• All causes of macroscopic haematuria
11. CAUSES OF PAINFUL & PAINLESS HAEMATURIA
PAINFUL HAEMATURIA
• Infection
• Stone
• Trauma
• PKD
• Loin pain haematuria syndrome
• Hemorrhagic cystitis due to
cyclophosphamide
PAINLESS HAEMATURIA
• Glomerulonephritis , commonly IgA
nephropathy
• Renal tuberculosis
• Tumors of urinary system
• Bleeding disorder or anticoagulant
therapy
• Bilharziasis ( schistosomiasis)
• Interstitial nephritis
12.
13. Clinical assessment of haematuria
history
How much bleeding? Is the urine discoloured or frankly bloody?
Recent trauma?
Previous episodes?
History of stone disease?
Relevant medications?
Recent instrumentation of the urinary tract?
Any associated urinary symptoms?
14. Clinical assessment of haematuria
history Contd…
Pain?
Sudden onset of colicky flank pain suggests a stone.
Suprapubic pain may indicate infection or clot colic.
Painless macroscopic haematuria indicates a tumour until proved
otherwise.
15. Clinical assessment of haematuria
history Contd..
What part of the stream?
Initial haematuria suggests an anterior urethral lesion.
Terminal haematuria usually arises from the posterior urethra,bladder, bladder
neck, or trigone.
Continuous haematuria usually originates at, or above, the level of the bladder.
Cyclical haematuria in female suggests endometriosis of the urinary tract.
16. Clinical assessment of haematuria
history Contd…
Risk factors for urothelial malignancy ?
Recent skin or throat infection — post-streptococcal GN.
Episodic macroscopic haematuria with throat infections is a classical presentation of
IgA nephropathy .
Recent travel?
Systemic symptoms, e.g. arthralgia, rashes, suggestive of an underlying inflammatory
disorder?
Family history of deafness or other renal disease- Alport’s syndrome
17. Physical examination
• Haemodynamically status?
• Anaemia.
• Bruising/bleeding s bleeding diathesis.
• Skin or throat infections ( post-infectious GN).
• Rashes, swollen joints ( inflammatory condition, e.g. vasculitis).
Cardiorespiratory:
• Stigmata of endocarditis.
• ↑BP and oedema ( glomerular disease).
18. Physical examination Contd..
Abdomen:
• Flank tenderness ( stone disease, pyelonephritis).
• Masses.
• Bruit ( AVM).
• Prostate.
• Consider testicular examination and VE ( misinterpreted vaginal bleeding).
20. Investigations Contd..
Imaging: plain x-ray KUB, USG KUB, IVU
CT with and without contrast, is the investigation of choice.
Cystoscopy (in virtually all patients)
Ureterography or ureteroscopy.
Angiography (rarely)- May demonstrate a vascular lesion.
Anti GBM antibody, ANA, AntidsDNA,ANCAs,complement,HBsAg,AntiHCV,
Anti HIV
Renal biopsy