Approach to hematuriaAAAAAAAAAAAAAAA (2).pptx

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1. Presented by: Mena Omar & Nadia Talal APPROACH TO HAEMATURIA

2. Haematuria : Haematuria means blood (RBCs) in the urine. It is classified as: Visible haematuria ( VH) : Previous terminology (macroscopic or frank or gross haematuria ). The patient or doctor has seen blood in the urine or describes the urine as red or pink. Visible haematuria strongly suggests significant urological disease and always requires further evaluation

3. Haematuria : Non-visible haematuria (NVH): (microscopic or dipstick haematuria ). Blood is identified by urine microscopy or by dipstick testing. Defined as 5 or more(RBCs) per (HPF), or ≥ 1+ by urine dipstick .

4. Haematuria : Non-visible haematuria (NVH): NVH either incidentally found in asymptomatic persons (asymptomatic a-NVH), or in patients with urinary symptoms e.g. LUTs (symptomatic s-NVH). Persistent NVH : positive 2 out of 3 urinary dipstick tests, otherwise it is transient hematuria and could be due to: • Urinary tract infection • Exercise-induced haematuria • Menstruation • Myoglobinuria The challenge lies in differentiating benign causes from serious pathology

5. Haematuria : It is important to differentiate haematuria from : Contamination in menstruating women Other causes of urine discolouration • Drugs: Chlorpromazine, metronidazole, nitrofurantoin , • Beetroot, blackberries • Myoglobinuria ( rhabdomyolysis ) and hemoglobinuria • Porphyrins • Mercury and lead poisoning (rare )

6. Haematuria THAT NEED EVALUATION: Any single episode of VH. Any single episode of s-NVH . (exclude transient causes i.e UTI) NVH in patients aged 40y or more. Persistent a-NVH .

7. CAUSES OF HAEMATURIA: Surgical causes: Medical causes :

8. Causes of haematuria : Surgical causes : INFECTION : Bacterial Women are prone to UTIs. UTIs in men <50 years old are uncommon. Sexually transmitted infections should be specifically investigated in this cohort. Common clinical features of lower UTI include frequency, dysuria, urgency, malodorous urine and visible or dipstick haematuria In acute pyelonephritis there is typically loin pain, fever , rigors and significant systemic upset. UTI is likely if a dipstick test is positive for either nitrite or leucocyte esterase, but is unlikely if both are absent. MSU culture confirms the diagnosis .

9. Causes of haematuria : Surgical causes: INFECTION : Atypical Urinary tuberculosis ( TB) : may cause visible haematuria ± other urinary tract symptoms, pulmonary manifestations and constitutional upset Urinalysis is positive for WBC but routine culture is negative. Diagnosis requires a fresh early morning urine sample for acid- /fast bacilli and TB culture. Schistosoma haematobium infection: , the most common initial presenting feature p ainless visible haematuria toward the end of voiding, which is most commonly acquired in Egypt/East Africa, e.g. by swimming in freshwater lakes. (clue to diagnosis travel history and eosinophilia)

10. Causes of haematuria : Surgical causes: STONES: Stones may be formed from Calcium oxalate (80%, associated with hypercalciuria ), Calcium phosphate (10% linked to renal tubular acidosis and hyperparathyroidism),or Urate (excessive meat consumption or chemotherapy) Struvite ( staghorn calculi, associated with chronic urinary tract infection) Cystein e ( rare nherited disorders ). Those in the renal pelvis or bladder may remain asymptomatic for years and present incidentally with dipstick haematuria .

11. Causes of haematuria : Surgical causes: STONES : Stones may cause obstruction anywhere along the urinary tract, though typically at sites of narrowing, e.g. the pelvi -ureteric junction, pelvic brim and vesico -ureteric junction. Ureteric obstruction typically presents with renal ‘colic’ – acute, severe loin pain radiating to the groin ± genitalia that builds to a crescendo of intensity over a few minutes, often accompanied by restlessness nausea and vomiting. The pain persists until obstruction is relieved. Visible haematuria may occur and dipstick is positive in 90% of cases.

12. Causes of haematuria : Surgical causes : TUMOR: Renal cancers : 60% present with haematuria . Associated features may include loin pain, abdominal mass and systemic upset Bladder cancers : 80 % present with haematuria that may be associated with (LUTS ), e.g. dysuria, frequency, urgency and hesitancy Both tumour types: are rare below the age of 40. However , in the majority of cases, haematuria is the sole symptom and examination is normal. Prostate cancers : around 12% of present with haematuria (more commonly microscopic).

13. Causes of haematuria : Surgical causes : TRAUMA: Direct urethral trauma; blunt or penetrating abdominal/pelvic injury. Iatrogenic: renal biopsy, transurethral resection of prostate, cystoscopy, urinary catheterisation . OTHERS: Inflammation: cyclophosphamide cystitis, interstitial cystitis. Benign prostatic hyperplasia (BPH), Vascular : arterio -venous malformations; renal vein thrombosis . Renal cysts

14. Causes of haematuria : Medical causes: RENAL DISEASES Haematuria may occur as a result of disorders that disrupt the glomerular basement membrane (glomerulonephritis ). Associated features include proteinuria , hypertension, oedema and renal failure . Those most likely to result in haematuria include anti-glomerular basement membrane disease ( Goodpasture’s syndrome), small-vessel vasculitis , e.g. Wegener’s granulomatosis , poststreptococcal glomerulonephritis , SLE and ( IgA ) nephropathy. In IgA nephropathy there may be intermittent episodes of visible haematuria coinciding with upper respiratory tract infections. Diagnosis of glomerular disease is made by renal biopsy. Inherited renal disorders , such as Alport’s syndrome and adult polycystic kidney disease, may also present with visible or non-visible haematuria .

15. Causes of haematuria : Medical causes : Coagulation disorders (e.g. haemophilia ), Anticoagulation therapy (e.g. warfarin), Sickle cell trait or disease, Renal papillary necrosis, Vascular disease (e.g. emboli to the kidney cause infarction and haematuria Loin pain- haematuria syndrome. Thin basement membrane disease (common, benign, often familial ).

16. CASE: A 60 -year-old man attends the ED complaining of a 3-week history of blood in the urine . he has also noted the passage of some small blood clots . he has had an intermitten t urinary stream for the past 24 h and complains of pain in the suprapubic region on voiding. he has been complaining of urinary frequency and urgency for the past 6 months . he smokes ten cigarettes per day. On examination of the abdomen, there is some minor suprapubic tenderness and a palpable bladder . The rest of the examination is unremarkable. His pulse rate is 100/min and the blood pressure is 105/70 mmHg. His investigations: HB: 8.2 g/ dL (11.5–16.0 g/Dl) WBCs: 13.6 × 109/L (4.0–11.0 × 109/L) Platelets: 400 × 109/L (150–400 × 109/L) Serum Sodium: 134 mmol /L (135–145 mmol /L) Serum Potassium: 4.8 mmol /L (3.5–5.0 mmol /L) Urea: 6.7 mmol /L (2.5–6.7 mmol /L) Creatinine : 92 µ mol /L (44–80 µ mol /L) What is the most probably diagnosis?

17. HAEMATURIA WORKUP: HISTORY: PHYSICAL EXAMINATION: INVESTIGATIONS: TREATMENT:

18. HISTORY : Age and sex : Age >40, cancer is the most common cause of hematuria, Urologic cancer is more common in males ; UTI is more common in females. Details of haematuria : Duration Frequency: intermittent/ continuous Timing of VH during urinary stream : – Initial hematuria—anterior urethral pathology – Terminal hematuria—bladder neck, prostate, or urethra inflammation/pathology – Hematuria throughout— vesical or upper-tract origin

19. HISTORY : Details of haematuria : Presence of clot : indicates significant degree of hematuria and higher probability of significant pathology – Amorphous clots—bladder/prostate origin – Vermiform clots—upper tract origin Associated pain: – Painless hematuria suggests bladder cancer – Flank pain, VH, and abdominal mass is pathognomonic of renal cell carcinoma – Ureteral colic/flank pain can be caused by calculi (most common), tumor, or blood clot – UTI/prostatitis can cause hematuria associated with dysuria, urgency, and suprapubic pain.

20. HISTORY : Detalis of haematuria : Lower urinary symptoms (frequency, urgency, etc.): – BPH can cause hematuria – Incomplete bladder emptying can predispose to bladder stones and infection – Straining to urinate or spraying of urinary stream can indicate a urethral stricture Activity/exercise-induced hematuria should be excluded General status , e.g. weight loss, reduced appetite, fever and chills Trauma —significant crush injury or burn may result in myoglobinuria ; abdominal or pelvic trauma may cause urinary tract injury

21. HISTORY : Medical or surgical history : – Renal or urologic disease or surgery – Recent urethral instrumentation(including catheterization ) – Sexually transmitted diseases (STDs) – History of tuberculosis (TB) – History of pelvic radiation – History of autoimmune diseases and bleeding disorders – Recent upper respiratory infection—associated with GN or immunoglobulin A (IgA) nephropathy Drugs history : – Nephrotoxic drugs: (e.g. P enicillin, Aminoglycosides) – Analgesic abuse (NSAIDs) – Cyclophosphamide – Anticoagulants (Warfarin) – D rugs predispose urolithiasis : (e.g. Acetazolamide, Allopurinol, Thiazide)

22. HISTORY: Menstrual & sexual history : Vaginal bleeding can be mistaken for hematuria Family history : – Primary renal disease – Hypertension (HTN) – Adult polycystic kidney disease – Alport syndrome – Urolithiasis – Urologic malig nancy Social history : – History of smoking tobacco – Occupational risk factors: Exposures to chemicals or dyes (aromatic amines, benzenes) in rubber, petroleum, and dye industries—risk of urothelial carcinoma – Travel abroad, e.g. swimming in lakes is Africa and Egypt and the risks of schistosomiasis

23. PHYSICAL EXAMINATION : GENERAL: • Pallor : Anemia may be associated with SLE, hemolytic anemia, and CKD OR may be due to sever hematuria. • Rashes : Consider Henoch – Schönlein purpura , SLE, and vasculitis • Generalized edema : Associated with nephrotic syndrome or renal failure VITAL SIGNS : BP : If hypertensive evaluate for renal parenchymal disease, CKD, renal cystic disease or renal vascular disease; May be hypotensive if hematuria persistent/severe. Temperature: Fever suggest UTI .

24. PHYSICAL EXAMINATION : ABDOMINAL: Flank lacerations, contusions or rib fractures—underlying renal injury Palpable abdominal or flank masses – Hydronephrosis , renal cystic disease, renal tumors, distended bladder Flank tenderness: – Pyelonephritis or urolithiasis A bruit could indicate a vascular process ( i.e., aneurysm or arteriovenous malformation ). Pelvic exam: – Urethral caruncle or vaginal prolapse, vaginal bleeding Digital rectal exam (DRE) – Boggy, tender, warm prostate suggests acute prostatitis – Nodularity suggest cancer – High-riding prostate suggests urethral disruption in presence of pelvic fracture

25. INVESTIGATIONS : Laboratory: Urinalysis : Must include standard urine dipstick and microscopic evaluation: – Color Bright red: Suggests recent or ongoing bleeding with urologic/anatomic origin Brown (tea-colored): Suggests old blood/clots or medical renal disease (GN) – Dipstick Specific gravity: Poorly concentrated urine—low specific gravity (<1.007) suggests hydronephrosis with renal impairment or intrinsic renal disease Proteinuria: Heavy (3–4+) suggests GN or renal disease Leukocyte esterase and/or nitrite positive ( pyuria ) suggests infection – Microscopy Pyuria – suggests infection Red cell casts – pathognomonic of glomerular bleeding Crystalluria – suggests urolithiasis Urine culture: If urinalysis suggests infection

26. INVESTIGATIONS: Laboratory Urinary cytology – Recommended for all patients with risk factors or irritative voiding symptoms. – Better at detecting high-grade urothelial carcinoma and CIS – Negative result does not rule out malignancy and Atypical cells can be seen with calculi or inflammation Renal function tests ( creatinine and BUN) CBC – anemia may be due to GH or chronic renal disease. Elevated (WBC) with a left shift suggests infection Peripheral smear (for sickle cell disease/trait) Coagulation profile studies (PT, PTT, INR) to identify coagulopathy

27. INVESTIGATIONS: Laboratory Other lab tests as clinically indicated – Streptozyme ( antistreptolysin O titer), serum complement, and antinuclear antibody (ANA), total serum proteins, and albumin: Globulin ratios for GN – Urinary calcium: Creatinine ratio (for hypercalciuria ), – TB skin test, and urinary mycobacterial cultures (for TB)

28. INVESTIGATIONS : Imaging Plain abdominal X-ray (KUB): Limited utility in initial evaluation of hematuria, may be useful in long-term follow-up of radiopaque stones Intravenous pyelography (IVU): Traditional imaging for the detection of stones, masses, or obstruction, largely replaced by CT urogram (CTU) CT urogram (CTU ): (with and without IV contrast) – The current gold standard for surveying the genitourinary (GU) tract for causes of hematuria; can detect stones (on noncontrast imaging), hydronephrosis and other anatomic abnormalities, renal masses, collecting system filling defects, lower urinary tract pathology – Non-contrast CT scanning is the procedure of choice to evaluate kidney stones but should not be used in the initial evaluation of hematuria .

29. INVESTIGATIONS : Imaging MRI – Alternative imaging modality when CT scanning is not advised . Ultrasound (US): – Detects renal cystic disease, renal masses, hydronephrosis , but less sensitive for detecting stone disease – Bladder: Useful to assess post-void residuals, can detect larger bladder tumors, bladder calculi and diverticuli , although less sensitive than CT scan. – Useful in children and pregnancy, when radiation is contraindicated. VCUG – Not routinely performed in work-up of hematuria in adults – May be done in children if hematuria is felt to be in conjunction with febrile UTI, concern for urethral obstruction, or other lower urinary tract abnormalities

30. INVESTIGATIONS: Imaging Nuclear renal scans: – Limited utility in the initial evaluation of hematuria Renal arteriography and venography – Useful for renal artery stenosis and renal vein thrombosis and preoperative elucidation of anatomy for surgical planning Retrograde urethrogram (RUG), cystogram as clinically indicated

31. INVESTIGATIONS : Diagnostic Procedures/Surgery Cystoscopy : – Should be performed in all patients >40 yr old with MH or GH – Patients <40 yr ; cystoscopy performed if significant risk factors for urologic malignancies present ( irritative voiding symptoms, tobacco history, chemical exposures, etc.) Retrograde pyelograms +/− ureteroscopy to evaluate the upper tract when IV contrast is contraindicated ( ie , contrast allergy/elevated creatinine ) or when upper tract pathology is suspected but not seen on less invasive imaging Renal biopsy: As directed by nephrologist when suspected glomerulonephritis (GN)

32. TREATMENT: GENERAL MEASURES: The standard urologic evaluation should include urinalysis, urine culture, cytology if risk factors, CTU and cystoscopy as outlined above Treatment depends on etiology. Consider and rule out causes of urine discoloration (by urinanalysis ) or medical causes of hematuria based on presentation, history, lab data, or if evaluation for anatomic lesion is negative Medical causes (renal diseases) suspected when dysmorphic red blood cells or red cell casts on microscopy, proteinuria , reduced/declining renal function, hypertension family history of renal disease or features of systemic disease

33. TREATMENT: VISIBLE HAEMATURIA: If patient is urinating without difficulty and has no blood clots can treat conservatively, (along with workup) Sometimes , patients with visible haematuria may present as an emergency . The most extreme example of this is those patients who have clot-retention . The patient presents with a history of prior visible haematuria with painful retention of urine and a palpable bladder, Urgent management should be done: The patient should be resuscitated with intravenous fluids and a blood crossmatch taken. (Transfuse RBCs if indicated for extreme acute blood loss) Bladder irrigation by urethral catheterisation with an irrigating (‘three-way ’) catheter , at least 20F in size. This allows both the relief of the retention , as well as the possibility to irrigate the bladder, with the intention of stopping the bleeding. Irrigating catheters allow better evacuation of blood clots than the standard two-way catheters .

34. TREATMENT: VISIBLE HAEMATURIA In most cases a rigid cystoscopy under GA will be required if there is continued bleeding. Cystoscopy and bladder washout will also be required where the bleeding is persistent and this may include diathermy of any bleeding points .(if the source of haematuria from bladder ).

35. TREATMENT: NON-VISIBLE HAEMATURIA: Work-up can be done in the outpatient clinic and usually requires no immediate monitoring or treatment unless associated with trauma Isolated microscopic haematuria is common and usually due to benign disease, e.g. thin basement membrane disease. Provided that the above causes have been excluded, reassure patients that further investigation is not necessary but continue to monitor (e.g. annually) for features such as new urinary tract symptoms , visible haematuria , proteinuria or renal impairment .

36. COMPLICATIONS: ANEMIA: It is rare for patients to experience complications from microscopic hematuria itself. But if the microscopic hematuria is severe (hundreds of RBCs per microscopic field on urinalysis) and prolonged, there may be some possibility that a patient will develop anemia, but more likely, the anemia will be the result of some other coexisting factors. A patient with recurrent or persistent gross hematuria, however, can easily become anemic, and such patients may need treatment for this condition as part of their overall management

37. COMPLICATIONS: CLOT RETENTION: A patient with severe, gross hematuria can experience urinary clot retention, as the clots may be too large to pass through the urethra. These clots require evacuation through a large Foley catheter or sometimes through a cystoscope under anesthesia, or bladder rupture could result. A patient with significant bleeding from a kidney may be able to pass clots through the urethra but may still experience clot “colic ” similar to the pain felt with passing a ureteral calculus. Such discomfort is often severe and generally requires parenteral analgesics for management.

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