This document discusses hematuria (blood in the urine) and obstructive uropathy (blockage of urine flow in the urinary tract). It covers evaluating hematuria through urinalysis, imaging tests, and cystoscopy. Common causes of hematuria include infections, stones, tumors, and glomerulonephritis. Obstructive uropathy can be congenital or acquired and cause changes to the urethra, bladder, ureters, and kidneys over time. Relieving the obstruction through surgery, stents, or nephrostomy is the main treatment approach.

1. Hematuria & obstructive Uropathy

2. Hematuria

3. Physical Examination of Urine an evaluation of color, turbidity, specific gravity and osmolality, and pH.

6. The reagent strip that detects blood utilizes hydrogen peroxide, which catalyzes a chemical reaction between hemoglobin (or myoglobin) and the chromogentetramethylbenzidine

8. Centrifuged urine

9. Centrifuged urine In hemoglobinuria, the supernatant will be pink. This is because free hemoglobin in the serum binds to haptoglobin, which is water insoluble and has a high molecular weight. This complex remains in the serum, causing a pink color. Free hemoglobin will appear in the urine only when all of the haptoglobin-binding sites have been saturated.

10. Centrifuged urine In myoglobinuria, the myoglobin released from muscle is of low molecular weight and water soluble. It does not bind to haptoglobin and is therefore excreted immediately into the urine. Therefore, in myoglobinuria the serum remains clear.

11. Quantity of Hematuria Microscopic Hematuria : seen only under microscope Gross Hematuria : visible, urine is pink, cola, red 5 times the number of life-threatening conditions when compared with patients with microscopic hematuria.

13. At what time during urination does the hematuria occur (beginning or end of stream or during entire stream)?

14. Is the hematuria associated with pain?

15. Is the patient passing clots?

17. Total Hematuria Terminal Hematuria Initial Hematuria

19. Painful micturition

20. inflammation of the bladder or prostate.

21. Colicky groin pain

22. ureteral calculus.

23. Burning pain in the penis or urethral opening in women

24. urinary infection.

25. Pain in the perineum associated with dysuria, fever, and rigors

26. seen in prostatitis.

27. Constant dull flank pain

29. Clots The presence of clots usually indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.

33. PCKD, Hematologic abnormalities

34. Trauma

35. Neoplasm

36. Benign or malignant

37. Infection/Inflammation

38. Metabolic

39. Stone

40. Miscellaneous

45. IgA nephropathy (Berger's disease)

46. Familial nephritis or Alport's syndrome

47. Goodpasture's syndrome

48. Systemic Lupus erythematosus

50. Non-glomerular Hematuria Characterized by circular erythrocytes and the absence of erythrocyte casts

51. An algorithm for the evaluation of nonglomerular hematuria

53. Phase contrast microscopy

54. BUN/serum creatinine: Elevated levels of BUN and creatinine suggest significant renal disease as the cause of hematuria

55. Hematologic and coagulation studies: CBC counts , Platelet counts

56. Urine calcium : A calcium excretion of more than 4 mg/kg/d or a urine calcium-creatinine ratio of more than 0.21 are considered abnormal.

57. Serologic testing

59. Urinary tract anomalies, such as hydronephrosis, hydroureter, nephrocalcinosis, tumor, and urolithiasis, are readily revealed with ultrasonography

60. Compared with other imaging studies, sonography is rapid, noninvasive, readily available, and devoid of exposure to radiation

62. A spiral CT scan is particularly useful in the detection of urolithiasis, Wilms tumor, and polycystic kidney disease

63. Voiding cystourethrograms are valuable in detecting urethral and bladder abnormalities that may result in hematuria (eg, cystitis)

66. Heavy smoking

67. Pelvic radiation

68. Exposure: dyes benzene

69. Chronic urological tract infection- Urine 24-hr, calcium - Imaging - Cystoscopy + Cytology No - Imaging - Cystoscopy + Cytology Yes

70. Obstructive Uropathy

71. Definition Functional or anatomic obstruction of urinary flow at any level of the urinary tract

73. Benign/malignant

74. Partial/complete

75. Unilateral/bilateral

77. ureteral strictures

78. posterior urethral strictures

80. vesical tumor

81. neurogenic bladder

82. extrinsic ureteral compression

84. History taking: Present Illness 2.Upper urinary tract ( ureter and kidney) -pain in the flank radiating along the course of the ureter -gross hematuria (from stone) -GI symptoms -fever with chills - may be asymptomatic

85. Physical Exam: Present Illness Signs Lower urinary tract -Palpation of urethra -Vesical distention

86. Physical Exam: Present Illness 2. Upper urinary tract -Palpation of kidney

87. Pathogenesis (pathophysiology) The changes in the various segments in the urinary tract, depending on the obstructive severity and duration 1. Urethral changes: dilatation, diverticulum

88. 2. Bladder changes: trabeculation , trigone hypertrophy , diverticulum

89. 3. Ureteral changes: distention, dilatation and hydroureter

90. 4. Pelvicalyceal changes: first shows evidence of hyperactivity and hypertrophy and then progressive dilatation and followed by flattening of the papillae and finally clubbing of the minor calyces. 5. Renal Parenchymal Changes : compression, ischemic atrophy.

92. Clinical findings 1.Symptoms and signs: infravesical obstruction :difficulty of voiding,weak stream ,diminished flow rate,terminal dribbling,burning ,frequency. Supravesical obstruction :renal pain or renal colic,if gradually--asymptomatic or enlarged kidney

93. Clinical findings 2.Laboratory findings Urinalysis BUN Creatinine Impaired kidney function elevated blood urea nitrogen and serum creatinine

94. Clinical findings 3.X-Ray findings , IVP, Cystoscopy , Retrograde pyelography localizing the site of obstruction demonstrate the extent of the obstructed segment anatomic changes functional changes

95. Clinical findings 4.Special Examination Instrumental calibration of sites of obstruction is also valuable radioisotope renography ultrasonic examination shows hydronephrosis and residual urine Urine flow rate CT

96. Treatment 1. Relief of obstruction -BPH or obstructing bladder tumors require surgical removal -impacted stones must be removed

97. Treatment 2.urethral stricture can be dilatated or urethrotomy or urethroplasty

98. Treatment 3.Percutaneous nephrostomy or double –J stent 4.GFR< 10% : nephrectomy

99. Thank You