Haematuria  Causes And Workup
Learning Objectives <ul><li>To be able to enumerate causes of hematuria </li></ul><ul><li>To be able take elaborate histor...
Hematuria <ul><li>Gross  blood in urine </li></ul><ul><li>Microscopic  3 to 5 RBCs per HPF </li></ul><ul><li>Always abnorm...
<ul><li>Terminal : proximal urethra, baldder neck/trigone, Iniial: distal to ext sphincter, total baldder / upper tract ( ...
Surgical Causes <ul><li>Kidneys </li></ul><ul><ul><li>Congenital – polycystic, PUJ, medullary sponge kidney </li></ul></ul...
Surgical Causes <ul><ul><li>Ureters </li></ul></ul><ul><ul><ul><li>Stones, TCC ureter, VUR, stricture, </li></ul></ul></ul...
Surgical Causes <ul><li>Urethra </li></ul><ul><ul><li>Trauma, rupture, stone, catheter trauma </li></ul></ul><ul><ul><li>I...
Surgical Causes <ul><li>Miscellaneous  </li></ul><ul><ul><li>Endometriosis  </li></ul></ul><ul><ul><li>Diverticulitis </li...
Surgical Causes <ul><li>False hematuria food colors / drugs staining red (beet roots, Dindevan, pyridium,furadantin, rifam...
Medical Causes <ul><li>Systemic disorders </li></ul><ul><ul><li>Haematological  </li></ul></ul><ul><ul><ul><li>Bleeding di...
Points in history <ul><li>Pain – renal, ureteric stone, clot, cysts, hydronephrosis, adv. Tumors, trauma </li></ul><ul><li...
Clinical examination <ul><li>No physical sign / Anything could be found  </li></ul><ul><li>Disoriented – liver / renal fai...
Workup <ul><li>Esteblish hematuria  - dipstick </li></ul><ul><li>Urine RE/microsscopy-RBCs </li></ul><ul><li>Urine CS – in...
Imaging: US <ul><li>cheap, easy, easily available, noninvasive, no countraindication, nontoxic, no side eff/reaction </li>...
Disadvantages  US <ul><li>: good for renal parenchyma but not for pelvicaliceal system, ureter annd not very good for blad...
IVU <ul><li>Conventional </li></ul><ul><li>Invasive ( IV contrast, side eff/ adverse eff – anaphylaxis, toxicity,- drug, r...
IVU <ul><li>Principle  </li></ul><ul><li>Indications </li></ul><ul><ul><li>Stone, hematuria, trauma, congenital abnormalit...
Cystoscopy  <ul><li>Visualizes lower tract starting at ext meatus, leading to bladder.( U, P, BN, ) </li></ul><ul><li>blad...
Urinary cytology, flow cytometery, tumour markers-NMP22, BTA <ul><li>May be helpful, being noninvasive, but not establishe...
Hematuria of obscure origin <ul><li>20% </li></ul><ul><li>Just explain that investigations that are usually carried oout h...
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Heamaturia

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lecture by Dr. Ahmed Rehman

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Heamaturia

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

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