Approach to a patient with hematuria.pptx

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1. Approach to a patient with hematuria IAMzelalem@16 Zelalem Antonios c-1

2. O utlines I ntroduction Etiology History Examination Investigation Management 2

3. Haematuria … Introduction Haematuria occurs when there is blood in the urine. currently, classified as visible haematuria (VH) or nonvisible haematuria ( NVH). Older terminology referred to macroscopic (or frank or gross) haematuria and microscopic (or dipstick) haematuria . 3

4. Introduction… Macroscopic or gross haematuria Urine may vary in colour from red to stale brown or chocolate coloured . May be associated with clots. Gross hematuria with passage of clots usually indicates a lower urinary tract source but can be seen with some forms of intrarenal bleeding ( eg , kidney cancer ). 4

5. Introduction… The nature of clots may give a clue to the source or site of bleeding. Serpiginous or vermiform clots indicate bleeding from the kidneys. Amorphous clots are suggestive of lower tract bleeding. Specifically, among patients with GH, 50% have been found to have a demonstrable cause, with 20% to 25% found to have a urologic malignancy, most commonly bladder cancer and kidney cancer . 5

6. Introduction… Gross hematuria is suspected because of the presence of red or brown urine. The color change does not necessarily reflect the degree of blood loss, since as little as 1 mL of blood per liter of urine can induce a visible color change. In addition, the intermittent excretion of red to brown urine can be seen in a variety of clinical conditions other than bleeding into the urinary tract. 6

7. Introduction… Acute kidney injury —   Gross (visible) hematuria occurring in patients with underlying glomerular disease has been associated with the development of transient acute kidney injury. This is best described in patients with IgA nephropathy patients with thin basement membrane disease and lupus nephritis who were over- anticoagulated with warfarin (international normalized ratio [INR] >4.0) or other anticoagulants such as dabigatran 7

8. Introduction… Microscopic haematuria It is defined as the presence of more than 3 RBCs per high power field on microscopic examination. It is usually detected incidentally on urine dipstick testing and subsequent microscopic examination. 8

9. Introduction… MH is quite common, with a prevalence of approximately 6.5 % of adults, varying according to the characteristics of the population. Malignancy has been detected in approximately 4% of patients evaluated for asymptomatic MH. The proportion of malignancies detected is higher in patients with higher degrees of hematuria and/or risk factors for malignancy. 9

10. Etiology Evaluation : Numerous investigative modalities are available for evaluation of haematuria . The choice of the correct modality depends on the clinical suspicion and important clues on clinical examination . A list of potential causes for haematuria can be rapidly generated by considering trauma (T), infection (I) and neoplasm (N) at all levels of the urinary tract from kidney to urethra. 10

11. CAUSES OF HAEMATURIA I . In the kidney 1. Infection • Acute glomerulonephritis • Tuberculosis 2. Infarction • emboli causing renal infarction • Massive haemolysis with acute renal tubular necrosis • Mismatched blood transfusion 3. Injury • Stab/blunt injury 11

12. CAUSES… 4. Tumours • Wilms ' tumour : Nephroblastoma • Renal cell carcinoma (RCC) • Transitional cell carcinoma (TCC) 5. Stones 6. Polycystic kidney 12

13. CAUSES… II . In the ureter 1. Stone 2. Cancer-rare Ill. In the urinary bladder I. Carcinoma of bladder 2. Carcinoma prostate 3. Cystitis 4. Tuberculosis 5. schistosomiasis 6. Stone: 7 . Benign prostatic hyperplasia (BPH ) 13

14. CAUSES… 14

15. CAUSES… Common causes Urolithiasis Tumours Uncommon causes Tuberculosis Cystitis , Polycystic kidney anticoagulants Sickle cell anaemia Bleeding disorders 15

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18. HISTORY AND EXAMINATION 1 . Age and sex Young children Young adults Elderly patients 2. Occupation Aniline dye workers Vesical calculus Renal stones , tuberculosis (TB) Renal cell carcinoma (RCC) Carcinoma bladder 18

19. History…. 3. Haematuria • Bright red • Altered blood • Profuse • Small quantity • Beginning of micturition • End of micturition • Lower urinary tract • Kidney • Papilloma • Renal cell carcinoma, TB, stone • Urethral pathology • Bladder pathology 19

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21. History…. It can be initial, terminal or throughout the stream. Urethral bleeding usually manifests as the first 10-15 ml of blood-stained urine , which gradually clears. Terminal haematuria usually indicates trigonal irritation ( e.g. bladder stone). It is usually associated with dysuria and strangury . Bleeding from the upper urinary tract ( kidneys,bladder and ureters) is seen throughout the stream as the blood mixes with the urine stored in the bladder . 21

22. History…. A recent upper respiratory infection or symptoms of upper respiratory disease raise the possibility of postinfectious or infection-related glomerulonephritis, immunoglobulin A (IgA) nephropathy, vasculitis , anti-glomerular basement membrane (GBM) disease, or sometimes hereditary nephritis . 22

23. History…. A positive family history of renal disease, as in hereditary nephritis, polycystic kidney disease, or sickle cell disease . Unilateral flank pain, which may radiate to the groin, usually suggests ureteral obstruction due to a calculus or blood clot but can occasionally be seen with malignancy or IgA nephropathy. 23

24. History…. Recent vigorous exercise or trauma in the absence of another possible cause of Exercise-induced hematuria. Cyclic hematuria in women that is most prominent during and shortly after menstruation, suggesting endometriosis of the urinary tract. Contamination with menstrual blood is always a possibility and should be ruled out by repeating the urinalysis when menstruation has ceased. 24

25. History…. Black patients should be screened for sickle cell trait or disease, which can lead to papillary necrosis and hematuria. Travel or residence in areas endemic for Schistosoma haematobium or tuberculosis . Sterile pyuria with hematuria, which may occur with renal tuberculosis, analgesic nephropathy, toxic nephropathy, and other interstitial diseases . 25

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27. Discoloration of the urine/ pigmenturia Many drugs and foodstuffs have been reported to produce abnormal discolouration of the urine. Most colours have been reported but the most frequently encountered clinically are red/orange and brown . Clearly, haematuria is the commonest cause for red urine; 27

28. Discoloration of the urine… the presence of haem in the urine also produces red discolouration and generates a positive dipstick test . Red urine discolouration due to haemoglobinuri a may present in haemolytic disorders such as ‘ march haematuria ’, classically seen in dehydrated soldiers after prolonged marching . 28

29. Discoloration of the urine… Likewise , myoglobinuria due to myocyte destruction , e.g. caused by rhabdomyolysis after crush injury, can also result in red discolouration of the urine . Rule out other causes (exercise , sexual activity, menstrual contamination) 29

30. Discoloration of the urine… This discolouration is due to the excretion of betalain ( betacyanin ) pigments such as betanin . The commonly used antibiotics nitrofurantoin and metronidazole can lead to the urine being discoloured brown. Brown urine due to high-circulating bilirubin is also a feature of obstructive jaundice . 30

31. Discoloration of the urine… Several medications can cause red/orange discolouration of the urine, most commonly rifampicin, isoniazid or phenazopyridine with tears and other bodily fluids generally also discoloured . Others include chlorpromazine, thioridazine , senna and laxatives containing a phenolphthalein component. Consumption of large quantities of beetroot can result in red discolouration of the urine. 31

32. General physical examination Evaluate G/A to CNS Gross pallor • Significant blood loss Gross pallor with minimal blood loss Hypertension Polycystic kidney Bony pains Carcinoma (prostate ) 32

33. physical examination… 5. Abdominal examination • Palpable kidney • Distended bladder • Suprapubic tenderness • Craggy epididymis and beaded vas • Polycystic kidney, Wilms ‘ tumour , renal cell carcinoma • Carcinoma prostate, enlarged prostate • Bladder stone, cystitis • Genitourinary tuberculosis 33

34. physical examination… Rectal examination • Enlarged smooth prostate [BPH] • Hard irregular prostate[ Carcinoma prostate] • Hard, thickened seminal vesicles • Advanced growth • Genitourinary tuberculosis • Carcinoma rectum infiltrating urinary bladder 34

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36. INVESTIGATIONS Urine examination • Worm-like clots • Flat disc-like • Pieces of tumour Growth in the ureter • Urethra 2. Urine microscopy • Pus cells • Abacterial acid pyuria • Malignant cells positive Urinary tract infection 36

37. INVESTIGATIONS… 37

38. INVESTIGATIONS… Plain X-ray KUB Enlarged kidney Radio-opaque shadows Polycystic kidney, Renal stones, ureteric stones, bladder stone 38

39. INVESTIGATIONS… 4. Cystoscopy Growth in the bladder Inflammation of the bladder Ulcers , hyperaemia , golf-hole ureter Papilloma bladder/TCC Cystitis TB 39

40. INVESTIGATIONS… 5. Intravenous urography • Spider leg calyces • Irregular calyces • Missing calyces Polycystic kidney Radio opaque stones 6 . Ultrasound Enlarged kidney Renal cell carcinoma Polycystic kidney Wilms ' tumour Stones 7. R etrograde urethrogram . A concern for traumatic urethral injury should prompt 40

41. INVESTIGATIONS… 8. Urine cytologic examination is highly sensitive and specific for the detection of high-grade urothelial carcinoma, its sensitivity decreases significantly for low-grade urothelial carcinoma, resulting in an overall sensitivity of 15.8% to 54.5% , and specificity of 95.0% to 100% for bladder cancer detection. 41

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43. Diagnostic algorism 43

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45. UNEXPLAINED HEMATURIA    If no diagnosis is apparent from the history, urinalysis, imaging exams, or cystoscopy, then the most likely causes of persistent isolated hematuria are mild glomerulopathy and a predisposition to stone disease , particularly in young and middle-aged patients. 45

46. Haematuria -management algorithm 46

47. R eferences Campbell-Walsh Urology vols. 1-4 , pdf Bailey&Love , A SHORT PRACTICE O SURGEY, 27 th ed., 2018. Smiths general urology 17 th ed. Urology, A Handbook for Medical Students . S.Brewster , D.Cranston , J.Noble and J.Reynard Uptodate 21 Schwartz's Principles of Surgery, 2019 47

48. Thank you