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).

5. CLASSIFICATION OF HAEMATURIA Contd..
Transient haematuria
• Exercise ( ‘ joggers ’ nephritis ).
• Menstruation.
• Sexual activity.
• Viral illnesses.
• Trauma.

7. CAUSES OF HAEMATURIA

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

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).

19. Investigations
Urinalysis:
• Urine R/M/E
• Phase contrast microscopy
• Urine C+S
Urine cytology: malignant cells?
Casts and dysmorphic red cells?
24 hour UTP,ACR,PCR
FBC,BT,CT
Blood sugar
S creatinine, blood urea
S electrolytes

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