very good

1. Hematuria-US
Haematuria-UK
Undergrads

2. Why is this topic important?
• Metastatic urothelial
malignancies are
incurable
• The earliest sign of
urothelial cancer is
Haematuria
• 5-25% of patients with
haematuria have
urologic malignancies
J Urol(2000) 163;524-7

3. At the end of undergraduate
medical training
1. Define and classify haematuria..
2. Identify risk factors that increase the likelihood of finding
malignancy during evaluation of haematuria.
3. Discuss evaluation of haematuria in a cost effective manner.
4. Discuss the initial management of severe haematuria and clot
retention

4. DEFINITION
• The presence of red blood cells in urine
• Gross-Visible to the patient
• Microscopic-Detected by the dipstick
method or microscopic examination of the
urinary sediment

5. 1.Dipstick method
• Depends on the ability of
haemoglobin to oxidize a
chromogen indicator
• The degree of the indicator
color change is proportional to
the degree of hematuria.
• Sensitivity of 95% and a
specificity of 75%
• Free haemoglobin, myoglobin
and certain antiseptic solutions
(povidone-iodine) will also give
positive readings
• Presence of significant
proteinuria (2+ or greater)
suggests a nephrologic origin
for hematuria.
• Positive results should be
confirmed with a microscopic
examination of the urine

6. 2.Microscopic examination of urine
• Performed on 10 mL of a
midstream, clean-catch
specimen that has been
centrifuged for 10 minutes at
2000 rpm.
• The sediment is
resuspended and examined
under high power
magnification.
• Microscopic hematuria is
defined as > 3 red blood cells
per high powered field
(rbc/hpf) on two of three
specimens(AUA)
• The presence of red cell casts,
dysmorphic red blood cells,
leukocytes, bacteria and
crystals should also be
included in the report

7. THE DEFINITION OF
SIGNIFICANT HAEMATURIA
• Some degree of haematuria will be found in 9
to18 percent of normal individuals
• Patients with three or more RBC/HPF on at least
two out of three properly collected
(Contamination, menstruation/haemorrhoids )
and properly performed urinalyses or a single
episode of high grade (>100RBC/HPF)
• Macro haematuria or gross haematuria should
be evaluated

8. ETIOLOGY
• kidney→urethral
meatus
Classification
1. Glomerular
2. Non glomerular

9. glomerular
• red cell casts,
dysmorphic red blood
cells and significant
proteinuria
• significant proteinuria
(>1,000 mg/24 hours)
likely indicates a renal
parenchymal process
• Nephrologist
consultation

10. Common Causes of Glomerular
Haematuria
• IgA nephropathy (Berger’s disease)
• Thin glomerular basement membrane
disease
• Hereditary nephritis (Alport’s syndrome)

11. Glomerular versus
extra(Non)glomerular bleeding
Urinary finding Glomerular Extraglomerular
Red cell casts May be present Absent
Red cell
morphology
Dysmorphic Uniform
Proteinuria May be present Absent
Clots Absent May be present
Color May be red or brown May be red

12. No-glomerular hematuria
• Upper or lower
urinary tract?

13. Upper urinary tract causes of
haematuria
• Nephrolithiasis
• Pyelonephritis
• Renal-cell cancer
• Polycystic kidney disease Polycystic
kidney disease
• Medullary sponge kidney
• Hypercalciuria, hyperuricosuria, or
both, without documented stones
• Renal-pelvis or ureteral transitional-cell
cancer
• Renal trauma
• Papillary necrosis-Sickle cell trait or
disease
• Renal infarction
• Ureteral stricture and hydronephrosis
• arteriovenous malformation
• Renal tuberculosis in endemic areas or
in patients with HIV infection

14. Lower urinary tract causes of
haematuria
•
• Bladder cancer
• Benign bladder and
ureteral polyps
• Benign prostatic
hyperplasia
• Prostate cancer
• Urethral and meatal
strictures
• Schistosoma
haematobium
• Cystitis, prostatitis, and
urethritis
• Instrumentation(catheter)

15. Uncertain
• Exercise hematuria (“marathon runner’s
hematuria)
• “Benign hematuria” (unexplained
microscopic hematuria)
• Over-anticoagulation (usually with
warfarin)
• Factitious hematuria (usually presents with
gross hematuria)

16. What percentage of patients
with haematuria have urological
cancers?
• Microscopic : about 5-10%
• Macroscopic: about 20-25%

17. Evaluation
• The medical history is the cornerstone of the evaluation

18. History
• Is the haematuria gross or microscopic?
• At what time during urination does the
haematuria occur beginning (initial ) or
end(terminal) of stream or during entire
stream(total)?
• Is the haematuria associated with pain?
• Is the patient passing clots? If the
patient is passing clots, do the clots have
a specific shape?

19. Gross versus Microscopic
Haematuria
• The chances of identifying significant
pathology increase with the degree of
haematuria.
• Patients with gross haematuria have
approximately five times the yield of life
threatening conditions when compared to
microhaematuria patients

20. Timing of Haematuria.
• Initial - usually from the
urethra
• Total- most likely coming
from the bladder or upper
urinary tracts
• Terminal - usually
secondary to
inflammation in the area
of the bladder neck or
prostatic urethra

21. Presence of Clots
• indicates a more significant degree of
haematuria
• probability of identifying significant urologic
pathology increases

22. Shape of Clots
• amorphous - bladder
or prostatic urethral
origin
• vermiform
(wormlike) clots-
particularly if
associated with flank
pain, identifies the
haematuria as coming
from the upper
urinary tract

23. Association with Pain
• Inflammation or
obstruction
• pain in association
with haematuria
usually results from
upper urinary tract
haematuria with
obstruction of the
ureters with clots

24. History
• Lower Urinary
Tract Symptoms
Storage (Irritative) and
Voiding(obstructive)
• Fever and Chills

25. Past Medical History
• History suggestive of
schistosomiasis
• Previous urological Surgery Procedures
• Smoking
• History of chemical exposure
(cyclophosphamide, benzenes, aromatic
amines TIE AND DYE
• History of pelvic radiation

26. Family history
• Sickle cell
• urolithiasis
• Polycystic kidney disease
• Bleeding diathesis

27. HIGH RISK for harbouring
malignancies /significant disease
• Gross haematuria
• History of schistosomiasis
• Storage lower urinary tract symptoms (urgency,
frequency, dysuria
• Prior urologic disease or treatment
• Age >40 years
• History of cigarette smoking
• History of chemical exposure
(cyclophosphamide, benzenes, aromatic amines
TIE AND DYE
• History of pelvic radiation

28. PHYSICAL EXAMINATION
• General Observations – pallor
,lymphadenopathy ,Cachexia
• Kidneys
• Bladder
• Penis
• Rectal and Prostate Examination in the
Male
• Pelvic Examination in the Female

29. kidney
• Tenderness-
infections
• Mass- Tumour,
Hydronephrosis

30. Bladder
• A normal bladder in the
adult cannot be palpated
or percussed until there
is at least 150 mL of urine
in it
• Bimanual examination,
best done with the patient
under anaesthesia, is
invaluable in assessing
the regional extent of a
bladder tumour or other
pelvic mass

31. Prostate
• Digital rectal
examination
(DRE) should be
performed in every
male after age 40
years and in men
of any age who
present for urologic
evaluation

32. INVESTIGATIONS
• GENERAL
1. Full blood count
2. BUE & Cr
3. Urinalysis
4. OTHERS
URINALYSIS (NORMAL VALUES/REF RANGE)
• Color – Yellow (light/pale to dark/deep amber)
• Clarity/turbidity – Clear or cloudy
• pH – 4.5-8
• Specific gravity – 1.005-1.025
• Glucose - Negative
• Ketones – None
• Nitrites – Negative
• Leukocyte esterase – Negative
• Bilirubin – Negative
• Urobilirubin – Small amount (0.5-1 mg/dL)
• Blood - ≤3 RBCs
• Protein - ≤150 mg/d
• RBCs - ≤2 RBCs/hpf
• WBCs - ≤2-5 WBCs/hpf
• Squamous epithelial cells - ≤15-20 squamous
epithelial cells/hpf
• Casts – 0-5 hyaline casts/lpf
• Crystals – Occasionally
• Bacteria – None
• Yeast - None

33. Urinalysis & Culture
• The number of red blood cells per high
powered field
• The presence of absence of red cell casts
and/or dysmorphic red blood cells
• The presence of white blood cells and
bacteria
• URINE C/S- If +ve Treat and Repeat
urinalysis AFTER 6WKS

34. Diagnostic studies
• The history and physical examination
often narrows down the probable
source of bleeding and allows the
Doctor to select the most appropriate
diagnostic studies

35. URINE CYTOLOGY
Urine collection
• First voiding in the morning on
three consecutive days
• Bladder washout
• Ureteric catheterization
+ve cytology(abnormal urothelial
cells
high nuclear: cytoplasmic ratio,
hyperchromatic nuclei,
prominent nucleoli
• SENSITIVITY 66%
• SPECIFICITY 95-100%

36. IMAGING
• Plain X-ray(KUB) -GH 60
• ULTRASOUND-GH 200
• IVU-GH400
• CT SCAN-GH600
• MRI-GH900

37. Plain x-Ray
Kidney ureter &bladder(KUB)
40 yr. old with haematuria, fever and colicky
left flank pain

38. Ultrasound. 60 yr. old woman with haematuria,
right flank pain and LUTS
• noninvasive, quick, portable,
requires neither radiographic
contrast media nor ionizing
radiation, and is relatively
inexpensive.
Can reveal
Renal mass(solid/cystic)
• stones
• Hydronephrosis
• Bladder mass ETC
Cannot visualise ureter
• The best starting point for
evaluating the renal units

39. IVU
1. normal renal
function, (Serum
creatinine
>170µmol/l
2. not pregnant
3. no allergies to
contrast material
4. Filling defects and
calyceal Distortion

40. CT SCAN

41. CT- With Reconstruction
40yr old with haematuria and right colicky flank
pain. Left flank surgical incision

42. MRI

43. Endourology
• Urethrocystoscopy
• Ureteronephroscopy

44. Urethrocystoscopy

45. Forceps biopsy of bladder tumour

46. Transurethral resection (TUR)
biopsy

47. Ureteroscopy

48. Challenges in GH!!
late presentation of bladder cancer
• Haematuria of over
2yrs duration
• Severe anaemia and
uraemia
• ? Renal death
• ? exsanguination
• ? cancer death

49. Radical cystectomy and
lymphadenectomy

50. ILLIAL conduit

51. Urostomy bags
• £8/bag

52. Massive Haematuria
• Admit the patient
• In clot retention, pass a wide bore
urethral catheter (22Fr or above) to
facilitate the washing out of clots.
Wash out by hand using a catheter tip
syringe(Bladder syringe) until all the
clots have been evacuated. A three
way catheter for the continuous
irrigation of the bladder must be
passed if bleeding is very heavy.
• If the patient can void and empty his or
her bladder then catheterization is not
necessary. Serial collection of
voided urine can be used to monitor
the resolution or otherwise of the
bleeding
• Resuscitate –IVF,GXM Blood, ETC
• Take a detailed history and perform a
thorough physical examination to
identify the source and cause of the
bleeding.

53. Conclusions
• 5-25% of patients with haematuria are
discovered to have a urologic cancer
• IN PATIENTS WITH HAEMATURIA,A
DIAGNOSIS OF BLADDER CANCER SHOULD
ALWAYS BE AT THE BACK OF YOUR MIND.

54. Conclusions

55. CASE 1
A 45 year old man who farms along the Volta Lake presents to the urology clinic with a two year
history of intermittent passage of blood in his urine. He recollects experiencing a similar episode of
urinating blood 30yrs ago. He has also recently noticed increased frequency and urgency of
micturition at 2 hourly intervals .He reports a good flow with no other symptoms suggestive of
bladder outlet obstruction.
a) What may be the most likely diagnosis and why?
b) Discuss possible differential diagnosis
c) Discus important signs you will look out for on physical examination of this patient
d) Discuss the investigations you would order for this man?

56. MARKING SCHEME
a) CancerofBladder-Grosshaematuria,IrritativeLUTS,exposuretobilharzia
b) Cystitis,prostatitis,BPH,CAP,Bladdercalculi,Renalcancer,uppertracturothelial
malignancies
c) Pallor,signsofrenalfailureformobstructiveuropathy,Cachexia,bladderMass.suprapubic
tenderness,renalmass(hydronephrosisfromuretericobstruction)),livermass,Ascites,DRE,
Bimanualexamination
d) FBC,UrineR/E,UrineC/S,Urinecytology(highlyspecificbutnotsensitive),BUE&Cr.
AbdominalandpelvicUSG/CTScan/MRI,cystoscopyandBiopsy(Cuporresection)

57. Further Reading
• Baja’s principles and
practice of surgery
including pathology in
the tropics, 5th
Edition.
• Companion in
Surgical Practice