Hematuria

HEMATURIA

1. HEMATURIA
BY
DR.MOHAMED ASHRAF MOSTAFA
MS.FRCS

2. HEMATURIA
•Definition :
presence of blood in the urine.
•The passage of blood in the urine is
always alarming and investigation is
warranted.

3. COMMON CAUSES OF
RED URINE
•Hematuria.
•Hemoglobinuria, myoglobinuia.
•Anthrocyanin in beets and blackberries.
•Chronic lead and mercury poisoning.
•Phenolphthalein (in bowel evacuants).
•Phenothiazines (compazine).
•Rifampicin.

4. :agnote tfnDi:rYsi TYPES OF HEMATURIA
MACROSCOPIC (Gross(
MICROSCOPIC: SYMPTOMATIC
ASYMPTOMATIC(with
(proteinuria or isolated(
INITIAL
TERMINAL
TOTAL

5. CAUSES OF HEMATURIA
MEDICAL
UROLOGICAL

6. MEDICAL CAUSES OF HEMATURIA
Nephrological
Ig nephropathy, post
Infectious g.n.
Less commonly,membrano-
proliferative g.n.,H.S.purp
Coagulation
disorders, hemophilia
anticoagulants.S.C.
disease, renal pap.
necrosis, vascular disease,
emboli to kidney

7. UROLOGICAL CAUSES
CANCER: Bladder (TCC,SCC(, Kidney (adeno-
carcinoma(, Renal pelvis & ureter (TCC(
Prostate.
Stone disease : kidney, ureter, bladder
Infection: bacterial, parasitic(schistomiasis(
Inflammatory: drug induced e.g.cyclophosphamide
interstitial cystitis.
Trauma: kidney, bladder, urethra
Renal cystic disease, vascular malformations
BPH

8. IS MICROSCOPIC HEMATURIA
ALWAYS ABNRMAL?
•A few RBCs can be found in urine of normal people.
•40% of soldiers has mic.hematuria on at least one
occasion and 15% on 2 or more occasions.
Transient hematuria :
•Rigorous exercise,
Sexual intercourse or
Menstrual contamination.

9. DIAGNOSIS OF HEMATURIA
HISTORY
•Age and sex.
•Smoking.
•History of schistomiasis in endemic areas.
•Occupational exposure to carcinogens.
•Drugs e.g. NSAID, Cyclophosphamides.
•Pain, fever, dysuria, frequency.
•History of clots suggests extraglomular cause.
•History of recent throat pain suggests post
infectious g.n.
•Information about exercise, menstruation recent
catheterization or passage of calculi.

10. COMMON CAUSES OF HEMATURIA BY
AGE& SEX
•0-20 yr :
Acute glomerulonephritis
Acute UTI
Congenital UT anomalies with obstruction
•20-40 yr
Acute UTI
Stones
Bladder cancer

11. COMMON CAUSES OF HEMATURIA BY
AGE& SEX
•40-60 yr (men)
bladder tumor
Stones
Acute UTI
•40-60 yr (women)
Acute UTI
Stones
Bladder tumor
•60 yr
BPH (men)
Bladder tumor
Acute UTI

12. Risk Factors for Significant Disease in
Patients with Microscopic Hematuria
Smoking history
Occupational exposure to chemicals or dyes
(benzenes or aromatic amines)
History of gross hematuria
Age >40 years
History of urologic disorder or disease

13. DIAGNOSTIC APPROACH OF HEMATURIA
PHYSICAL EXAMINATION
•BP
•General exam. : peripheral edema, petichiae.
Skin rashes and arthritis can occur in
Henoch-Schönlein purpura and
systemic lupus erythematosus

CVS : irregular cardiac rhythm,
murmur or hypertension.

•Abdomen : organomegaly or flank
mass.
•Ext. genitalia : meatal stenosis, phimosis,
urethral discharge.
•DRE : prostate.

15. DETECTION OF HEMATURIA
•Urine dipsticks test

- Urine dipsticks test for
presence of hemoglobin &
myoglobin in urine .
- Hem catalyses the oxidation of
orthotolidine by organic
peroxidase producing a blue
colored compound.
- Dipsticks are capable of
detecting the presence of
hemoglobin from 1 or 2 RBCs.

16. DIPSTICKS TESTS
•False positive results :
Myoglobinuria,
Bacterial peroxidases,
Povidine & hypochlorite.
• False negative results (rare):
Reducing agents ( e.g. ascorbic acid which
prevents oxidation of orthotolidine).

17. LABORATORY STUDIES
Urine microscopy
Fresh specimen:
Pyuria suggests infection/inflammation.
RBC casts suggest GN.
Dysmorphic RBC suggests renal origin
Urine c/s

18. LABORATORY STUDIES
1. 24 hours urine proteins
2. Low serum complement
- postinfectious glomerulonephritis, systemic lupus
erythematosus nephritis, bacterial endocarditis, and
membranoproliferative glomerulonephritis
3. Antinuclear antibody (ANA) and double-stranded
DNA
- systemic lupus erythematosus nephritisBUN & S.
Creatinine

20. LABORATORY STUDIES
Urine cytology:
- Detects 95% of grade III and invasive bladder
tumors. Sensitivity decreases for upper tract
disease.
- In pts with higher risk of bladder cancer like
older, smokers, long-standing
cyclophosphamide, negative cytology should
be followed by cystoscopy.

21. IMAGING STUDIES
Renal and bladder ultrasonography
Spiral CT
Voiding cystourethrography
Radionuclide studies

22. ULTRASONOGRAPHY
Urinary tract neoplasm,
stone disease,
inflammatory
processes, congenital
abnormalities, vascular
lesions, and
obstruction
Not likely to detect non
obstructing ureteral
stones or small
urothelial
abnormalities,

23. CT SCAN

24. INTRAVENOUS UROGRAPHY

25. MRI UROGRAPHY
Currently serves as an alternative imaging
technique for children and pregnant women and
for patients with a contraindication to iodinated
contrast media.
Urothelial cancers, stones, renal tumors

26. VOIDING CYSTOURETHROGRAPHY
Congenital
abnormalities of
UT

27. CYSTOSCOPY
Recommended for higher
risk patients.
If find lower tract disease on
cystoscopy , the upper
tracts should also be
evaluated

28. RENAL BIOPSY
Rarely indicated in the evaluation of isolated
asymptomatic hematuria.
Relative indications are as follows:
1.Significant proteinuria
2.Abnormal renal function
3.Recurrent persistent hematuria
4.Serologic abnormalities (abnormal complement,
ANA, or dsDNA levels(
5.Recurrent gross hematuria
6.A family history of end-stage renal disease

30. Peditric

32. Adult patient with
asymtomatic mic.
Hematuria

33. SUMMARY
•The passage of blood in the urine is always alarming
and investigation is warranted.
•Urine microscopic exam. Should be carried out in all
cases of +ve dipstick test
•Evaluation must be started with detailed
occupational, family and medical history
•Medical causes should be excluded before urologic
consultation
•U/S and CT scan are much helpful for evaluation of
patients with hematuria

34. SUMMARY
•Urine cytology and cystoscopy are included
in the work up for high risk patient group
•No abnormality is found in up to 70% of
patients with asymptomatic microscopic
hematuria despite full conventional urologic
investigation( urine cytology, cystoscopy,
ultrasonography and IVU(

35. THANK
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