Image of The Day 9: Traumatic Haematuria Muhamad Na’im B. Ab Razak (MD USM) Gross haematuria with blood clot in tubing after the insertion of CBD. at this moment, no need to do anything yet as the cause is obvious. if the bleeding continues, then proceed with irrigation.Walking through the ward, you will come across a patient with Folley’s catheter and CBDbag connected to it. Haematuria as i have being described in Image of The Day 7: RenalMass [link] could be a disaster as it is due to the neoplasm. However, it is only one out ofmore than 30 spectrum of disease that resulting from systemic, kidney, ureter, bladder andurethra. For today’s image of the day, i will discuss on traumatic haematuria.In patient with already pre-existing catheter, the first thing that should come into your mind isa traumatic haematuria secondary to catheter insertion. Apart from the direct trauma due tothe technique, the catheter itself can sometime cause irritation to bladder mucosa in certainpatient. It is usually mild and not require any intervention. All you need to do is to observe thecondition and KIV for bladder irrigation if not resolving.
In patient with no pre existing catheter who presented with hematuria, take note on thesethings. 1) To obtain information about any surgical procedure that patient has undergone.Patient with stenting placement post cystoscopy may cause minor bleeding. 2) History oftransurethral resection of the prostate and bladder tumor resection may explain the hematuria.3) Patient undergone laparotomy or pelvic surgery especially in obstetric and gynecology casemay have iatrogenic injury to the bladder and ureter during the manipulation.Last in the list for traumatic haematuria is trauma associated injury. Bear in minds that alltrauma patient must be inspected for bleeding from urethra meatus. While monitoring forurine output is crucial for trauma patient, Folley’s catheter insertion is an absolutecontraindication for this type of patient until retrograde urethrogram has being performed toexclude urethral injury. Hematuria in trauma patient may be due to renal parenchymal injuryor secondary injury to either bladder or urethra due to pelvic fracture.Differential diagnosis of non traumatic haematuria (will not going to be discussed in thisentry) would be URINARY TRACT INFECTION, stone, tumor, anticoagulation, structuralabnormalities (especially polycystic kidney), prostate lesion, glomerulonephritis,enterovesical fistula, vascular pathology (renal infarction, renal vein thrombosis, AVM), renalpapillary necrosis, hemorrhagic cystitis (a/w cyclophosphamide, chemotherapy with cytoxan),radiation cystitis, connective tissue disease, tuberculosis, sickle cell disease, contaminationfrom menses and benign essential heamaturia.When you examine the patient, look for any discoloration of the flank or suprapubic area, anybloody discharge from urethra, “free floating prostate” on per rectal examination that indicateurethral disruption and pelvic examination to rule out co –existence/ source with cervicalbleeding.Investigation should be ordered as according to the most likely diagnosis and aetiology.Routine examination would be FBC, coagulation study, UFEME (most of the time showsRBC only. But look for the present of cast as well), BUSE. Other radiological investigationmay include plain abdominal x ray, retrograde urethrogram, KUB Ultrasound cytoscopy.
If the haematuria is not associated with urethral injury and the haematuria is gross, then putthe three way catheter and irrigate with at least 6 pints of Normal Saline/ 24 hours and reevaluate the patient. Non resolving haematuria will require further irrigation and detailedevaluation. Anti fibrinolytic agent like Tranexamic acid can be used in life threatening orsevere haematuria before proceed with invasive modality.Finally, please remember that even though that the haematuria is likely due to trauma inorigin, please NEVER FORGET about the non trauma cause of haematuria. Think a way toexclude them! And always remember that UTI is also a common cause of Haematuria inpatient with CBD and female!!ii Reference: Alan T. Lefor, Leonard G. Gomella et al, “Surgery On Call”, 4th edition,Lange, 2006.i