Hematuria - evaluation and management

Hematuria - evaluation and management

1. EVALUATION AND
MANAGEMENT OF HEMATURIA
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

2. Moderators:
Professors:
•Prof. Dr. G. Sivasankar, M.S., M.Ch.,
•Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
•Dr. J. Sivabalan, M.S., M.Ch.,
•Dr. R. Bhargavi, M.S., M.Ch.,
•Dr. S. Raju, M.S., M.Ch.,
•Dr. K. Muthurathinam, M.S., M.Ch.,
•Dr. D. Tamilselvan, M.S., M.Ch.,
•Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

3. CLASSIFICATION
According to its visibility and timing during the
urinary stream
Gross/ Frank
•Initial
•Terminal
•Total
Microscopic
•Asymptomatic
•Symptomatic
3Dept of Urology, GRH and KMC, Chennai.

4. CLASSIFICATION
According to origin
•Urinary bladder
•Prostate
•Urethra
•Upper urinary tract
4Dept of Urology, GRH and KMC, Chennai.

5. TIMING OF HEMATURIA
Gives indication of the source of hematuria,
Initial
•Urethral source
Total
•Bladder or
above
Terminal
•Bladder trigone
•Bladder neck
•Prostate
5Dept of Urology, GRH and KMC, Chennai.

6. TIMING OF HEMATURIA
Initial
•Urethral source
Total
•Bladder or
above
Terminal
•Bladder trigone
•Bladder neck
•Prostate
6Dept of Urology, GRH and KMC, Chennai.

7. DIFFERENTIAL DIAGNOSIS
Pigmenturia
endogenous
sources
e.g., bilirubin,
myoglobin,
porphyrins
foods ingested
e.g., beets and
rhubarb
drugs taken
e.g.,
phenazopyridine
dehydration
7Dept of Urology, GRH and KMC, Chennai.

8. DIFFERENTIAL DIAGNOSIS
Pigmenturia
•Cause false-positivechemical tests (e.g., urine
dipstick)
•This distinction can be made easily by
urinalysis with microscopy.
8Dept of Urology, GRH and KMC, Chennai.

9. DIFFERENTIAL DIAGNOSIS
Vaginal bleeding in women
•obtaining a careful menstrual history
•collecting the specimen when the patient is
not having menstrual or gynecologicbleeding,
•if necessary, obtaining a catheterized
specimen
9Dept of Urology, GRH and KMC, Chennai.

10. MICROSCOPIC HEMATURIA
•Signrather than a symptom
•Laboratory diagnosis
•Definition
–Presence of RBCs on microscopic examination of
the urine not evident on visual inspection of the
urine.
•The prevalence of MH among healthy
participants in screening studies is
approximately 6.5%
10Dept of Urology, GRH and KMC, Chennai.

11. MICROSCOPIC HEMATURIA
•Higher rates noted in
–Males
–older patients
–smokers
•Categorizedby the presence or absence of
associated symptoms
•Quantifiedaccording to number of RBCs per
high-power field (HPF)
11Dept of Urology, GRH and KMC, Chennai.

12. Criteria for the Diagnosis
normal processes
(e.g., sexual
activity, exercise)
significant medical
conditions
(GU malignancy)
12Dept of Urology, GRH and KMC, Chennai.

13. Criteria for the Diagnosis
•Differences in thresholds for initiating an
evaluation reflect efforts to balance the
•Importantly, none have been robustly validated.
Benefits
Cost
analysis
Harms
13Dept of Urology, GRH and KMC, Chennai.

14. Criteria for the Diagnosis
Criteria
3 or more
AUA-Single UA
Canada, Dutch-2 out
of 3 UA
Japan-5 or more RBCs/
HPF on a single UA
Kaiser permanente-
More than 3 RBCs/HPF
on 2 out of 3 UAs
NICE-1+ blood or more
on urine dip stick test
PLUS Dysuria or
elevated leukocytosis
14Dept of Urology, GRH and KMC, Chennai.

15. URINE MICROSCOPY
Specimen collection
Centrifuge
Pipette, slide
Microscopy
15Dept of Urology, GRH and KMC, Chennai.

16. URINE MICROSCOPY
16Dept of Urology, GRH and KMC, Chennai.

17. DIPSTICK TEST
Dipsticks frequently demonstrate both colored dots and field color change
The degree of color change is directly related to the amount of hemoglobin present
which changes color according to the degree and amount of oxidation.
catalyzes the reaction and causes subsequent oxidation of a chromogen indicator
Haemoglobin in contact with an organic peroxidase substrate
17Dept of Urology, GRH and KMC, Chennai.

18. DIPSTICK TEST
•Free hemoglobinand myoglobin in the urine
•Absorbed into the reagent pad
•Catalyzethe reaction within the test paper
•Produce a field change effect in color.
18Dept of Urology, GRH and KMC, Chennai.

19. DIPSTICK TEST
coalescence of the dots occurs when there are more than 250 erythrocytes/mL
The greater the number of intact erythrocytes-greater the number of dots that will appear on the test paper
localized free hemoglobin on the pad produces a corresponding dot of color change.
undergo hemolysis
come in contact with the reagent test pad
Intact erythrocytes in the urine
19Dept of Urology, GRH and KMC, Chennai.

20. Requirement for Microscopic Evaluation
Urine dipstick for
blood
Haemoglobin,
myoglobin
Urine microscopy
3 or more
RBCs/HPF
Further Evaluation
Detects peroxidase
activity using
benzidine
20Dept of Urology, GRH and KMC, Chennai.

21. Requirement for Microscopic Evaluation
False
positive
False
Negative
dilute urine
(osmolality
<308mOsm)
Vigorous physical
or sexual activity
prolonged
recumbency
(first void in
morning)
21Dept of Urology, GRH and KMC, Chennai.

22. Selecting Patients for Evaluation
Vigorous exercise
•considered a diagnosis of exclusion.
•Thus it is necessary to confirm the absence of
MH after a period of abstinence from exercise
22Dept of Urology, GRH and KMC, Chennai.

23. Selecting Patients for Evaluation
Hematuriaand anticoagulants
•e.g., warfarin, enoxaparin, heparin, aspirin,
clopidogrel, apixiban, dabigatran
•Should undergo a complete evaluation in the
same manner as patients not taking such
medications
23Dept of Urology, GRH and KMC, Chennai.

24. Selecting Patients for Evaluation
•Prevalenceof hematuria, as well as the likelihood
of finding genitourinary cancers
–no different from patients not taking such medications
•May unmask genitourinary lesions at an earlier
stage
•Patients taking antithrombotic agents were more
than twice as likely to be diagnosed with bladder
cancer within 6 months after an episode of
hematuria
24Dept of Urology, GRH and KMC, Chennai.

25. Selecting Patients for Evaluation
25Dept of Urology, GRH and KMC, Chennai.

26. 26Dept of Urology, GRH and KMC, Chennai.

27. Selecting Patients for Evaluation
•ACOG, AUGS-2017: Witholdevaluation in
women if
–asymptomatic microscopic hematuria
–never-smoked
–35 to 50 years
–fewer than 25 RBCs/ HPF
•the risk of urinary tract malignancy in such
patients has been demonstrated to be less
than or equal to 0.5%
27Dept of Urology, GRH and KMC, Chennai.

28. Screening: Hematuriaand Bladder Cancer
•Mass screening for bladder cancer
–harms and costs outweigh the potential benefits
•Opportunistic screening events
–many primary care providers perform urinalysis as
part of routine health examinations
28Dept of Urology, GRH and KMC, Chennai.

29. +AMH
(≥3 RBCs/HPF on UA with
microscopy)
History and physical assessment
for other potential AMH causes
(e.g., infection, menstruation,
recent urologic procedures)
Repeat UA after treatment of
other cause(s).
Release from care
Follow Protocol of history and
Physical assessment: Negative
Renal function testing
Cystoscopy
Imaging (CTU)
Follow up with at least one
UA/micro yearly for at least 2
years.
Follow persistent MH with annual
UA. Consider nephrologic
evaluation. Repeat anatomic
evaluation within 3 to 5 years* or
sooner, if clinically indicated.
Release from care
Treatment and Follow up as
indicated by diagnosis. Reevaluate
for MH after resolution of
identified condition
Concurrent nephrologicworkup if
proteinuria, red cell morphology,
or other signs indicate
nephrologiccauses
+
+
+
+
-
-
-
-
29Dept of Urology, GRH and KMC, Chennai.

30. HISTORY
Goal should be to identify causes that would warrant
variation from the standard evaluation, such as
•Infection
•Menstruation
•Recent vigorous exercise
•Known medical renal disease
•Acute viral illness
•Trauma
•Presence of foreign bodies in the urinary tract
•Recent urologic instrumentation
30Dept of Urology, GRH and KMC, Chennai.

31. HISTORY
•Associated symptoms-
–GH, voiding symptoms, or flank pain.
•Urologic history
–any surgeries or febrile UTIs.
•General medical history
–to identify potentially contributory diagnoses
–hypertension, renal insufficiency, bleeding
disorders, or sickle cell disease.
31Dept of Urology, GRH and KMC, Chennai.

32. HISTORY
•Current medication use, including
–anticoagulants and antiplatelet therapies
–recent coagulation values
–any concomitant medications that would potentiate
the effects of blood thinners.
•Family history
–nephritis, polycystic kidneys, and rare familial tumor
syndromes of the kidney (e.g., von Hippel-Lindau
syndrome) or urothelium(e.g., Lynch syndrome) also
may be informative
•Tobacco use
32Dept of Urology, GRH and KMC, Chennai.

33. PHYSICAL EXAMINATION
•Focus on the genitourinary system
–flank tenderness
–masses in the flank, abdomen, suprapubic area, or
urethra;
–enlarged, nodular, tender, or fluctuant prostate
33Dept of Urology, GRH and KMC, Chennai.

34. PHYSICAL EXAMINATION
•Signs of coagulopathy (bruising)
•infection (fever)
•renal disease (hypertension, edema).
•If urethral stricture or BPH is suspected, a UFR
and PVR measurement may be helpful as well.
34Dept of Urology, GRH and KMC, Chennai.

35. +AMH
(≥3 RBCs/HPF on UA with
microscopy)
History and physical assessment
for other potential AMH causes
(e.g., infection, menstruation,
recent urologic procedures)
Repeat UA after treatment of
other cause(s).
Release from care
Follow Protocol of history and
Physical assessment: Negative
Renal function testing
Cystoscopy
Imaging (CTU)
Follow up with at least one
UA/micro yearly for at least 2
years.
Follow persistent MH with annual
UA. Consider nephrologic
evaluation. Repeat anatomic
evaluation within 3 to 5 years* or
sooner, if clinically indicated.
Release from care
Treatment and Follow up as
indicated by diagnosis. Reevaluate
for MH after resolution of
identified condition
Concurrent nephrologicworkup if
proteinuria, red cell morphology,
or other signs indicate
nephrologiccauses
+
+
+
+
-
-
-
-
35Dept of Urology, GRH and KMC, Chennai.

36. LABORATORY TESTING
•Urinalysis
–if not performed previously
–to confirm the presence of hematuria
–check for dysmorphic red cells, cellular casts, or
proteinuria
•Urine culture
–if the urinalysis or clinical presentation suggests infection
•Renal function testing (serum creatinine)
–to determine whether concomitant nephrologicevaluation
is indicated
–to guide the selection of appropriate upper tract imaging
•Prostate-specific antigen in the appropriate setting.
36Dept of Urology, GRH and KMC, Chennai.

37. CYSTOSCOPY
•Most reliable way to evaluate the bladder for
the presence of bladder cancer
•Provides the opportunity to evaluate the
urethra.
•The AUA guidelines
–all adults who are 35 years of age or older (<1 per
100,000) and/or have risk factors for malignancy.
37Dept of Urology, GRH and KMC, Chennai.

38. CYSTOSCOPY
Blue-light cystoscopy
•Using 5-aminolevulinic acid (ALA) or
hexylaminolevulinate(HAL) instillation
•Approved by the US FDA for evaluation of
patients with suspicion of papillary bladder
cancer
•Studies supporting its use have been conducted
in patients with known bladder cancer, thereby
limiting generalizability to MH patients
38Dept of Urology, GRH and KMC, Chennai.

39. CYSTOSCOPY
39Dept of Urology, GRH and KMC, Chennai.

40. CYSTOSCOPY
Blue-light cystoscopy
•Disadvantages
–rare anaphylactoidshock, hypersensitivity, pain,
cystitis, dysuria, hematuria
–risk for unnecessary biopsies compared with
conventional white light cystoscopy
•AUA guideline recommends against using
blue-light cystoscopy for evaluation of MH
40Dept of Urology, GRH and KMC, Chennai.

41. UPPER TRACT IMAGING
Multiphasic CT urogram
•CT with precontrast, nephrographic, and
excretory series
•Imaging study recommended by the AUA
•Offers complete imaging of the urinary tract
41Dept of Urology, GRH and KMC, Chennai.

42. CT UROGRAM
Unenhanced CT scan
42Dept of Urology, GRH and KMC, Chennai.

43. CT UROGRAM
Cortical
nephrographicphase
•25 to 80 s after
contrast medium
injection
•Reveals increased
enhancement of
the renal cortex (C)
relative to the
medulla (M).
43Dept of Urology, GRH and KMC, Chennai.

44. CT UROGRAM
Homogeneous
nephrographicphase
•85 and 120s after
contrast medium
administration
•reveals a
homogeneous,
uniform, increased
attenuation of the
renal parenchyma.
44Dept of Urology, GRH and KMC, Chennai.

45. CT UROGRAM
Excretory phase
•3 minutes after
contrast
medium
administration
•shows contrast
medium in the
RP bilaterally
45Dept of Urology, GRH and KMC, Chennai.

46. UPPER TRACT IMAGING
Multiphasic CT urogram
•Drawbacks
–may not be appropriate for all patients (e.g.,
pregnancy, iodinated contrast allergy, renal
insufficiency)
–uses a relatively high radiation dose (20–30mSv)-
risk of carcinogenesis
46Dept of Urology, GRH and KMC, Chennai.

47. CT UROGRAM
•CT urography is not as sensitive as cystoscopy for
the detection of urothelial tumorsin the bladder.
•Only large bladder tumorsare visualized with CT
imaging studies as filling defect in the lumen of
the bladder.
•Carcinoma in situ cannot be visualized on CT
scanning and therefore cystoscopy is still an
important part of a comprehensive hematuria
workup.
47Dept of Urology, GRH and KMC, Chennai.

48. UPPER TRACT IMAGING
•Magnetic resonance (MR) urogram
–In the setting of a contraindication to CT urogram
–contraindication
•Pacemaker
•significant renal function compromise (eGFR<30 and when
the administration of gadolinium risks nephrogenic systemic
fibrosis)
•NC CT or ultrasound, in conjunction with
retrograde pyelography to evaluate the calyces,
renal pelvis, and ureters, may be most
appropriate.
48Dept of Urology, GRH and KMC, Chennai.

49. UPPER TRACT IMAGING
US plus cystoscopy vs CT urogramplus cystoscopy
•more cost effective
•nearly the same diagnostic yield
•not risk stratified and importantly has not been
prospectively tested
49Dept of Urology, GRH and KMC, Chennai.

50. Urine Cytology
•Highly sensitive and specific for the detection
of HG urothelial carcinoma, LG-decreased
•Overall
–sensitivity of 15.8% to 54.5%
–specificity of 95.0% to 100% for bladder cancer
detection
50Dept of Urology, GRH and KMC, Chennai.

51. Urinary Biomarkers
•Nuclear matrix protein-22 (NMP-22)
•Fluorescence in situ hybridization (FISH)
•Immunocytologyfor CEA and mucin
glycoproteins (ImmunoCytand CertNDx)
51Dept of Urology, GRH and KMC, Chennai.

52. Urinary Biomarkers
NMP-22
•Offers a potential advantage in management of
patients with MH: it is available as a point-of-care
test.
•Only two studies have focused on AMH, with one
finding a high sensitivity (90.9%) and the other
demonstrating very low sensitivity (6.0%).
•Specificity was moderate or high in both studies
(76.3% and 82.5%, respectively)
52Dept of Urology, GRH and KMC, Chennai.

53. Urinary Biomarkers
NMP-22
53Dept of Urology, GRH and KMC, Chennai.

54. Urinary Biomarkers
FISH
•for abnormalities of chromosomes 3, 7, 17,
and 9p21
•UroVysion
•sensitivity and specificity of 61% and 93%,
respectively, for bladder tumors
54Dept of Urology, GRH and KMC, Chennai.

55. Urinary Biomarkers
FISH
55Dept of Urology, GRH and KMC, Chennai.

56. Urinary Biomarkers
Immunocytology
•ImmunoCyttest
–Antibodies directed against
•Mucin glycoprotein-Green
•CEA-Red
–sensitivity of 68.1%-87%.
56Dept of Urology, GRH and KMC, Chennai.

57. Urinary Biomarkers
Immunocytology
•CertNDx
–assesses several markers (mutant FGFR3, quantified
MMP-2, and hypermethylationof TWIST1 and NID2).
–Sensitivity-87.9% and specificity-56.3%
•A similar test, looking for methylation of TWIST1,
ONECUT2, and OTX1, along with mutation of
FGFR3, TERT, and HRAS
–sensitivity of 93% and specificity of 86%
57Dept of Urology, GRH and KMC, Chennai.

58. Urinary Biomarkers
•Current evidence
–none can replace cystoscopy or imaging,
–not recommended in the initial evaluation of
patients with AMH
•Cytologicexamination may be considered in
–patients with a negative initial workup in whom
urothelial carcinoma is still suspected, as well as in
–patients with symptomatic MH.
58Dept of Urology, GRH and KMC, Chennai.

59. GUIDELINE-BASED EVALUATION OF MH
Scenarios
•When the cause is diagnosed before complete
evaluation?
•When benign cause is diagnosed, need for
further evaluation?
•When medical Renal disease is diagnosed,
need for further evaluation?
•When the initial evaluation is negative?
59Dept of Urology, GRH and KMC, Chennai.

60. GUIDELINE-BASED EVALUATION OF MH
AUA guidelines
Upper tract
imaging
Renal cancer/
ureteral calculus
Cystoscopy
Clearance of
bladder and
urethral
pathology
60Dept of Urology, GRH and KMC, Chennai.

61. WHEN BENIGN CAUSE IS DIAGNOSED
ensure that the hematuriahas resolved in the absence of the presumed benign cause
urine should be retested
cause should be verified and treated
benign cause of hematuriais discovered (e.g., UTI)
Initial history and physical examination
61Dept of Urology, GRH and KMC, Chennai.

62. WHEN MRD IS DIAGNOSED
•If a medical renal cause of hematuriais
suspected based on the presence of renal
insufficiency, hypertension, or abnormalities
on urinalysis, nephrology evaluation is
recommended, but the patient should still
undergo urologic evaluation.
62Dept of Urology, GRH and KMC, Chennai.

63. Natural History of MH With a -veInitial
Evaluation
AUA Recommendation-
Negative workup
following up annual
urinalysis for 2 years
urinalyses confirm
resolution of hematuria
releasing the patient
from care
Persistent/recurrent
AMH or for development
of symptoms or GH
repeating the hematuria
evaluation within 3 to 5
years
63Dept of Urology, GRH and KMC, Chennai.

64. 64Dept of Urology, GRH and KMC, Chennai.

65. +AMH
(≥3 RBCs/HPF on UA with
microscopy)
History and physical assessment
for other potential AMH causes
(e.g., infection, menstruation,
recent urologic procedures)
Repeat UA after treatment of
other cause(s).
Release from care
Follow Protocol of history and
Physical assessment: Negative
Renal function testing
Cystoscopy
Imaging (CTU)
Follow up with at least one
UA/micro yearly for at least 2
years.
Follow persistent MH with annual
UA. Consider nephrologic
evaluation. Repeat anatomic
evaluation within 3 to 5 years* or
sooner, if clinically indicated.
Release from care
Treatment and Follow up as
indicated by diagnosis. Reevaluate
for MH after resolution of
identified condition
Concurrent nephrologicworkup if
proteinuria, red cell morphology,
or other signs indicate
nephrologiccauses
+
+
+
+
-
-
-
-
65Dept of Urology, GRH and KMC, Chennai.

66. SYMPTOMATIC MH
•Differential diagnosis-same as AMH.
•Risk for malignancy may be significantly higher
than in AMH (10.5% vs. 5.0% or less)
•Complete workup can be avoided
–In the setting of a symptomatic, culture-
documented urinary infection presenting with
hematuria, with documentation of hematuria
resolution after treatment
66Dept of Urology, GRH and KMC, Chennai.

67. SYMPTOMATIC MH
AUA guidelines(Changes from AMH)
•Cystoscopyis recommended in such patients
regardless of age
•Urine cytologicexamination is considered an
option in the setting of irritativevoiding
symptoms
67Dept of Urology, GRH and KMC, Chennai.

68. GROSS HEMATURIA
•As the degree of hematuriaincreases, so does
the likelihood of finding clinically significant
lesions during evaluation
•50%-demonstrable cause
•20% to 25% -urologic malignancy, most
commonly bladder cancer and kidney cancer
68Dept of Urology, GRH and KMC, Chennai.

69. GROSS HEMATURIA
•Recommended evaluation
–urine cytologicexamination
–Cystoscopy
–upper tract imaging, preferably CT urogram
•Exception
–antecedent trauma
–culture-documented UTI
69Dept of Urology, GRH and KMC, Chennai.

70. GROSS HEMATURIA
•GH must be assessed for hemodynamic
stability with careful attention to
–vital signs, anemiawith a complete blood count
•For patients on anticoagulation
–coagulation parameters to ensure that levels are
within the therapeutic range.
•After initial stabilization, diagnostic evaluation
should then proceed, with cause-specific
management.
70Dept of Urology, GRH and KMC, Chennai.

71. HEMORRHAGIC CYSTITIS
•Intractable hematurialocalizing to the bladder
•Characterized by diffuse inflammation and
bleeding from the bladder mucosa
•Unfortunately, patients in this situation are
often elderly and infirm, with medical
comorbidities that complicate plans for care
transient condition
that quickly resolves
after conservative
management
life-threatening
condition requiring
urgent intervention
71Dept of Urology, GRH and KMC, Chennai.

72. 72Dept of Urology, GRH and KMC, Chennai.

73. HEMORRHAGIC CYSTITIS
Bacterial infections
•common cause of GH
•symptomatic resolution typically noted after
appropriate treatment
73Dept of Urology, GRH and KMC, Chennai.

74. HEMORRHAGIC CYSTITIS
Viral-induced hemorrhagiccystitis
•may affect children and immunosuppressed adults
particularly (e.g., after renal or bone marrow
transplantation).
•BK virus
–member of the polyomavirus family, is the most common virus
•Adenovirus
–types 11 and 35
–correlated with HC in children and renal transplant patients
•Treatment
–primarily supportive, with hydration, diuresis, and bladder
irrigation, although case reports of success with antiviral
therapy exist
74Dept of Urology, GRH and KMC, Chennai.

75. HEMORRHAGIC CYSTITIS
Oxazaphosphorineclass of chemotherapeutic
agents
•Specifically cyclophosphamide and ifosfamide.
•Occur in 2% to 40% of patients treated with
cyclophosphamide
•Dose dependent.
75Dept of Urology, GRH and KMC, Chennai.

76. HEMORRHAGIC CYSTITIS
Onset of hematuria is typically within 48 hours of treatment
Subsequent tissue edema/fibrosis
Stimulates bladder mucosal sloughing
Excreted in kidney
Production of metabolite acrolinein liver
Cyclophosphamide
76Dept of Urology, GRH and KMC, Chennai.

77. HEMORRHAGIC CYSTITIS
Treatment
•2-Mercaptoethane sulfonate (mesna)
–binds to acroleinand renders it inert
–For prophylaxis against cyclophosphamide-induced HC
–10% to 40% -develop HC despite preventive treatment.
•Hyperhydrationwith forced diuresis and/or
continuous bladder irrigation
–Debate continues: mesnais more effective?
77Dept of Urology, GRH and KMC, Chennai.

78. HEMORRHAGIC CYSTITIS
Radiation therapy for pelvic malignancy
represents
•Moderate to severe hematuria-5% of patients
•Depend on
–radiation dosage
–mode of delivery
•onset between 6 months and 10 years after
treatment
78Dept of Urology, GRH and KMC, Chennai.

79. HEMORRHAGIC CYSTITIS
Further compromising tissue healing
Secondary infection frequently ensues
Local vascular compromise
Tissue necrosis and mucosal sloughing
Progressive obliterative endarteritis
Induce inflammation, fibrosis, and ischemia
Radiation damages the vascular endothelium,
79Dept of Urology, GRH and KMC, Chennai.

80. HEMORRHAGIC CYSTITIS
Receipt of both cyclophosphamide
chemotherapy and pelvic radiation
•Represents risk factors for bladder cancer
•Such patients presenting with hematuria
should be evaluated for bladder cancer before
the diagnosis of hemorrhagiccystitis is
assigned
80Dept of Urology, GRH and KMC, Chennai.

81. Cystectomy (with conduit uninarydiversion)
Internal iliac artery angioembolization
Formalin 4%
(repeat pre-Txcystogram)
Formalin 1%
Obtain pre-Txcystogram
Hyperbaric Oxygen Therapy (HBOT)
Continue supportive measures
• Add bilateral nephrostomy tubes for diversion of urine if hematuriacontinues, ±bilateral nephro-occlusive tubes
Hematuriacontinues after 48 hours
Initial management
• Hydration/diuresis
• Cystoscopy with clot evacuation ±fulguration, biopsy if concern for malignancy
• Continuous bladder irrigation
• Supportive care (transfusion prn)
• Address “correctable” factors (infection, coagulopathy, tumor)
• Intravesicalalum, PG, Na hyaluronate, Silver Nitrate, Aminocaproicacid
Diagnose hemorrhagiccystitis
• Patient with identified risk factors
• Hematuriaevaluation (UT imaging, urine cytology, urine culture)
81Dept of Urology, GRH and KMC, Chennai.

82. HEMORRHAGIC CYSTITIS-MANAGEMENT
Initial management-Intravesicalagents
•Alum
•Prostaglandins
•sodium hyaluronate
•Silver nitrate
•Aminocaproicacid
82Dept of Urology, GRH and KMC, Chennai.

83. HEMORRHAGIC CYSTITIS-MANAGEMENT
Alum
•Aluminumammonium sulfateor aluminum
potassium sulfate
•In small series, widely variable success rates
(e.g., 45% to 100%), with limited durability of
hematuriacontrol, have been reported after
alum instillation
83Dept of Urology, GRH and KMC, Chennai.

84. HEMORRHAGIC CYSTITIS-MANAGEMENT
•used to irrigate the bladder at a rate of 200 to 300mL/h.
1% alum solution
5L
sterile
water
50g
alum
84Dept of Urology, GRH and KMC, Chennai.

85. HEMORRHAGIC CYSTITIS-MANAGEMENT
Arrest bleeding
stimulate vasoconstriction and a decrease in capillary permeability
cause protein precipitation on the urothelial lining
Alum-Irrigation
85Dept of Urology, GRH and KMC, Chennai.

86. HEMORRHAGIC CYSTITIS-MANAGEMENT
Drawbacks
•Suprapubic discomfort and bladder spasms
•Systemic absorption
–aluminumtoxicity, with consequent mental status
changes, particularly among patients with renal
insufficiency.
86Dept of Urology, GRH and KMC, Chennai.

87. HEMORRHAGIC CYSTITIS-MANAGEMENT
Advantages
•Cell penetration and therefore overall toxicity of
this agent are low
•Instilled without anesthesia
•Overall relatively favorableefficacy and safety
profiles.
•Considered for first-line intravesicaltherapy
among patients failing initial supportive
measures, particularly among those without
renal insufficiency.
87Dept of Urology, GRH and KMC, Chennai.

88. HEMORRHAGIC CYSTITIS-MANAGEMENT
Prostaglandins
•Carboprosttromethamine[PGF2-α])
•Precise mechanism of activity remains unclear,
–Thought to cause vasoconstriction
–platelet aggregation
–cytoprotectionvia mucous barrier regulation.
•Response rates of 50% to 60% have been noted
•Difficulties with PGF2 access, storage, and high
costs have limited generalized utility
88Dept of Urology, GRH and KMC, Chennai.

89. HEMORRHAGIC CYSTITIS-MANAGEMENT
Intravesicalsodium hyaluronate
•As a defect in the bladder’s glycosaminoglycan
layer has been thought to contribute to the
pathogenesis of hemorrhagiccystitis
•Noted symptomatic improvement
89Dept of Urology, GRH and KMC, Chennai.

90. HEMORRHAGIC CYSTITIS-MANAGEMENT
IntravesicalSilver nitrate
•Result in chemical coagulation at bleeding
sites.
•A 0.5% to 1% solution is instilled for 10 to 20
minutes
•The potential for precipitation and upper tract
obstruction with this agent led to the
recommendation for a cystogramto rule out
reflux before administration
90Dept of Urology, GRH and KMC, Chennai.

91. HEMORRHAGIC CYSTITIS-MANAGEMENT
IntravesicalAminocaproicacid
•A lysineanalogue
•Competitive inhibitor of activators of
plasminogen, including urokinase
–thus interrupts fibrinolysis and the cascade that
perpetuates hemorrhage
•Continuous bladder irrigation with 200mg
aminocaproicacid/L of 0.9% normal saline has
been described
•Irrigation continued for 24 hours after hematuria
resolves.
91Dept of Urology, GRH and KMC, Chennai.

92. HEMORRHAGIC CYSTITIS-MANAGEMENT
IntravesicalAminocaproicacid
•Symptom resolution-92%of patients
•The risk for thromboembolic events may be
increased with this treatment
•Given only after the bladder has been
rendered clot free, because the agent will
otherwise lead to the formation of hard clots
difficult to eradicate from the bladder
92Dept of Urology, GRH and KMC, Chennai.

93. Cystectomy (with conduit uninarydiversion)
Internal iliac artery angioembolization
Formalin 4%
(repeat pre-Txcystogram)
Formalin 1%
Obtain pre-Txcystogram
Hyperbaric Oxygen Therapy (HBOT)
Continue supportive measures
• Add bilateral nephrostomy tubes for diversion of urine if hematuriacontinues, ±bilateral nephro-occlusive tubes
Hematuriacontinues after 48 hours
Initial management
• Hydration/diuresis
• Cystoscopy with clot evacuation ±fulguration, biopsy if concern for malignancy
• Continuous bladder irrigation
• Supportive care (transfusion prn)
• Address “correctable” factors (infection, coagulopathy, tumor)
• Intravesicalalum, PG, Na hyaluronate, Silver Nitrate, Aminocaproicacid
Diagnose hemorrhagiccystitis
• Patient with identified risk factors
• Hematuriaevaluation (UT imaging, urine cytology, urine culture)
93Dept of Urology, GRH and KMC, Chennai.

94. HEMORRHAGIC CYSTITIS-MANAGEMENT
Hyperbaric oxygen therapy (HBOT)
•When Hematuriaremains refractory to the
aforementioned measures
•Particularly with hemorrhagiccystitis resulting
from radiation therapy or cyclophosphamide
treatment
•HBOT is carried out in a specially designed
chamber
94Dept of Urology, GRH and KMC, Chennai.

95. HEMORRHAGIC CYSTITIS-MANAGEMENT
Hyperbaric oxygen therapy (HBOT)
•Involves administration of
–100% oxygen
–Pressure-2 to 3 atmospheres
–Duration-appr. 90 minutes
–30 to 40 sessions
•Response rates-80% to 90%
–maintained up to 2 ½ years after treatment.
•5-year complete response rate-only 27%
95Dept of Urology, GRH and KMC, Chennai.

96. HEMORRHAGIC CYSTITIS-MANAGEMENT
•HBOT
•local tissue oxygen tension increases
•oxygen extraction by tissues increases
•Diminish edema and promote neovascularization
•critical steps in the wound healing process
96Dept of Urology, GRH and KMC, Chennai.

97. HEMORRHAGIC CYSTITIS-MANAGEMENT
•Complications
–claustrophobia (20%), otalgia (17%), and, rarely,
seizures
•Bilateral nephrostomy tube insertion, with or
without occlusion of the ureters
–For patients with continued bleeding during therapy
–to decrease exposure of the hemorrhagicbladder to
urokinaseand thereby theoretically facilitate
hemostasis, particularly during the relatively
prolonged time course of HBOT
97Dept of Urology, GRH and KMC, Chennai.

98. Cystectomy (with conduit uninarydiversion)
Internal iliac artery angioembolization
Formalin 4%
(repeat pre-Txcystogram)
Formalin 1%
Obtain pre-Txcystogram
Hyperbaric Oxygen Therapy (HBOT)
Continue supportive measures
• Add bilateral nephrostomy tubes for diversion of urine if hematuriacontinues, ±bilateral nephro-occlusive tubes
Hematuriacontinues after 48 hours
Initial management
• Hydration/diuresis
• Cystoscopy with clot evacuation ±fulguration, biopsy if concern for malignancy
• Continuous bladder irrigation
• Supportive care (transfusion prn)
• Address “correctable” factors (infection, coagulopathy, tumor)
• Intravesicalalum, PG, Na hyaluronate, Silver Nitrate, Aminocaproicacid
Diagnose hemorrhagiccystitis
• Patient with identified risk factors
• Hematuriaevaluation (UT imaging, urine cytology, urine culture)
98Dept of Urology, GRH and KMC, Chennai.

99. HEMORRHAGIC CYSTITIS-MANAGEMENT
Intravesicalformalin
•Induces cellular protein precipitation and
capillary occlusion.
•Control of bleeding-80% to 90% of cases,
which are relatively higher rates than other
intravesicaltreatments.
•May induce significant pain, administration
under general or spinal anesthesiais
recommended
99Dept of Urology, GRH and KMC, Chennai.

100. HEMORRHAGIC CYSTITIS-MANAGEMENT
Complications
•Bladder fibrosis with associated decreased
bladder capacity
•Ureteral stricturingwith proximal
hydronephrosis/renal injury
•Thus pretreatmentcystogramis recommended to
exclude the presence of vesicoureteral reflux
and/or bladder perforation
•Patients must be counseledregarding the
potential impact on subsequent bladder function
100Dept of Urology, GRH and KMC, Chennai.

101. HEMORRHAGIC CYSTITIS-MANAGEMENT
If reflux is documented,
•placement of occlusive ureteral catheters is
recommended to limit upper tract exposure to
the medication.
•Low concentrations of formalin (1% to 4%)
should be used
101Dept of Urology, GRH and KMC, Chennai.

102. HEMORRHAGIC CYSTITIS-MANAGEMENT
Instillation
•Volume
–up to 300mL or to bladder capacity
•Should be done under gravity
–catheter no more than 15cm above the pubic symphysis.
•Instillation should be limited to 10 to 15 minutes
•Should be performed with the catheter on light
traction to prevent urethral exposure
•Care taken to protect all external areas of skin from
exposure.
102Dept of Urology, GRH and KMC, Chennai.

103. HEMORRHAGIC CYSTITIS-MANAGEMENT
IntravesicalFormalin
•Given the potential toxicities of formalin,
together with the requirement for
administration under anesthesia, this agent
should be reserved for second-line therapy
103Dept of Urology, GRH and KMC, Chennai.

104. Cystectomy (with conduit uninarydiversion)
Internal iliac artery angioembolization
Formalin 4%
(repeat pre-Txcystogram)
Formalin 1%
Obtain pre-Txcystogram
Hyperbaric Oxygen Therapy (HBOT)
Continue supportive measures
• Add bilateral nephrostomy tubes for diversion of urine if hematuriacontinues, ±bilateral nephro-occlusive tubes
Hematuriacontinues after 48 hours
Initial management
• Hydration/diuresis
• Cystoscopy with clot evacuation ±fulguration, biopsy if concern for malignancy
• Continuous bladder irrigation
• Supportive care (transfusion prn)
• Address “correctable” factors (infection, coagulopathy, tumor)
• Intravesicalalum, PG, Na hyaluronate, Silver Nitrate, Aminocaproicacid
Diagnose hemorrhagiccystitis
• Patient with identified risk factors
• Hematuriaevaluation (UT imaging, urine cytology, urine culture)
104Dept of Urology, GRH and KMC, Chennai.

105. HEMORRHAGIC CYSTITIS-MANAGEMENT
Internal iliac artery angioembolization
•Performed unilaterally or bilaterally
•Can be done even in debilitated patients, with
relatively limited risk
•Selective embolization of the anterior branch of
the internal iliac artery bilaterally is typically
required to achieve hemostasis
•May use any of a variety of embolic materials,
including gelatinmicrospheres, polyvinyl alcohol
particles, or coils
105Dept of Urology, GRH and KMC, Chennai.

106. HEMORRHAGIC CYSTITIS-MANAGEMENT
•Initial hemorrhagecontrol-90%
–durability of response-not been well established
•Reliabilityof this approach for patients after
radiation therapy in which mucosal ischemia
underlies the pathophysiology, remains
uncertain
106Dept of Urology, GRH and KMC, Chennai.

107. HEMORRHAGIC CYSTITIS-MANAGEMENT
•Complication: embolization of the posterior branch of
the internal iliac artery
•occlusion of the superior gluteal artery
•Gluteal muscle ischaemia
•significant gluteal pain.
107Dept of Urology, GRH and KMC, Chennai.

108. HEMORRHAGIC CYSTITIS-MANAGEMENT
Cystectomy with urinary diversion
•In the setting of failed angioembolizationand
other conservative approaches
•Supravesicalurinary diversionalone (e.g., ileal
conduit) without cystectomy
–Complications-up to 80% of patients with a retained
bladder
–specifically infection (pyocystis), with rehospitalization
in 43%
–suggesting that cystectomy should be performed at
the time of urinary diversion if feasible
108Dept of Urology, GRH and KMC, Chennai.

109. HEMORRHAGIC CYSTITIS-MANAGEMENT
•Typically elderly, infirm
–in poor condition for surgery.
•Perioperative complication rates
–significantly higher than what has been reported
after cystectomy for bladder cancer
•Balance the risks and benefits
109Dept of Urology, GRH and KMC, Chennai.

110. HEMATURIA FROM PROSTATIC ORIGIN
•Diagnosis made after a complete GH
evaluation (including cytology, upper tract
imaging, and cystoscopy) to confirm that no
other source of hematuriaexists
transient self-limiting
episodes
Continuous bleeding
resulting in the obstruction
of urinary flow and in
transfusion dependence
110Dept of Urology, GRH and KMC, Chennai.

111. HEMATURIA FROM PROSTATIC ORIGIN
Commonly due to
•BPH
•prostate-related infection (prostatitis)
•prostate cancer
111Dept of Urology, GRH and KMC, Chennai.

112. Prostate-related gross
hematuria
• Exclude other causes of hematuria
with UT imaging, urine cytology,
cystoscopy
Initial management
• Hydration/diuresis • Continuous
bladder irrigation • Supportive care
(transfusion prn)
• Address “correctable” factors (i.e.,
coagulopathy)
BPH
5 Alpha reductase
inhibitor
Clinical/comorbidity
status poor?
Cystoscopy with
fulguration
• Consider antiandrogen
therapy
Angioembolisation
BPH-related surgery
• HOLEP • TURP •
Simple • PVP
prostatectomy
Angioembolisation
Prostatitis
• Diagnose by clinical presentation
+ urine culture
Antibiotic therapy
Prostate cancer
(typically advanced)
Androgen deprivation
therapy ±external
beam radiotherapy
Cystoscopy with
fulguration/“channel”
TURP
Urinary diversion (pending
clinical status)
• Percutaneous nephrostomy
tube • Palliative prostatectomy/
cystoprostatectomywith conduit
diversion
Angioembolisation
112Dept of Urology, GRH and KMC, Chennai.

113. HEMATURIA FROM PROSTATIC ORIGIN
BPH
•Most common causeof prostate-related
bleeding
•Most common cause of GH in men older than
60 years
•Only pathological condition identified in
approximately 20% of cases from hematuria
studies .
113Dept of Urology, GRH and KMC, Chennai.

114. HEMATURIA FROM PROSTATIC ORIGIN
•Benign Prostatic hyperplasia
•Higher levels of VEGF
•Higher microvessel density
•Increased prostatic vascularity
•Prone to Haematuria
114Dept of Urology, GRH and KMC, Chennai.

115. HEMATURIA IN BPH-MANAGEMENT
•Expectant management with hydration
–Usually mild and selflimiting.
•Surgery
–Historically-indication for surgery
–increased understanding of the molecular
pathway contributing to the pathophysiologic
process
–targeted medical therapy
115Dept of Urology, GRH and KMC, Chennai.

116. HEMATURIA IN BPH-MANAGEMENT
Estrogensand antiandrogens
•Decreases prostate bleeding
•MOA-presumably
–through the repression of androgen-stimulated
angiogenesis and
–the induction of programmed cell death within
the prostate
116Dept of Urology, GRH and KMC, Chennai.

117. HEMATURIA IN BPH-MANAGEMENT
Finasteride,
•5α-reductase inhibitor that blocks conversion of
testosterone to dihydrotestosterone
•Treatment of outlet obstructive symptoms
•Investigated extensively for BPH-related
haematuria
•MOA-associated with decreased
–VEGF expression,
–prostate microvesseldensity
–prostatic blood flow
117Dept of Urology, GRH and KMC, Chennai.

118. HEMATURIA IN BPH-MANAGEMENT
•Demonstrated efficacy even in patients being
treated with anticoagulation.
•Symptom improvement or resolution-90%
•Onset of action
–Variable
–improvement in bleeding noted from as short as 2
weeksto up to 9 months after initiating therapy
•Who eventually require BPH surgery, concurrent
therapy with 5α-reductase inhibitors can
decrease perioperative bleeding complications
and morbidity
118Dept of Urology, GRH and KMC, Chennai.

119. HEMATURIA IN BPH-MANAGEMENT
TURP
•Patients with persistent bleeding from BPH
despite conservative therapies and/or
endoscopic fulguration
•Particularly when additional indications for
BPH surgery coexist
•Alternative
–Photoselectivevaporization of the prostate
–Holmium laser enucleation of the prostate
–Suprapubic/retropubicprostatectomy
119Dept of Urology, GRH and KMC, Chennai.

120. HEMATURIA IN BPH-MANAGEMENT
Selective prostatic artery embolization (PAE)
•Persistent bleeding despite TURP
•Typically bilateralembolization is performed
•Initial success-90%
•Recurrence in 15% to 28%
120Dept of Urology, GRH and KMC, Chennai.

121. HEMATURIA IN BPH-MANAGEMENT
Selective prostatic artery embolization (PAE)
•Superselectiveapproach
–specifically addressing the Prostatic arteries with
gelatinmicroparticles
•Selective approach
–embolization of the anterior branch of the internal
iliac artery has been used as well
121Dept of Urology, GRH and KMC, Chennai.

122. HEMATURIA IN BPH-MANAGEMENT
Selective prostatic artery
embolization (PAE)
Type I-Origin from anterior
division of IIA in a common
trunk with the superior
vesical artery (SVA)
Type II-Origin from
anterior division of IIA,
inferiorly to SVA
Type III-Origin from
obturator artery
Type IV-Origin from
internal pudendal artery
Type V-Less common
origins
122Dept of Urology, GRH and KMC, Chennai.

123. HEMATURIA IN BPH-MANAGEMENT
Radical prostatectomy or cystoprostatectomy
•Must be considered
•But usually are poor surgical candidates
because of comorbidity status
123Dept of Urology, GRH and KMC, Chennai.

124. HEMATURIA FROM PROSTATIC ORIGIN
Prostatitis
•Traditionally secondary to bacterial infection
•Hematuriaas the manifesting symptom in 2.5%of men
•The mechanism of hematuriain prostatitis
–unclear and may be related to inflammation
•Management
–Antibiotics when culture-documented bacterial prostatitis
is present.
–Significant recurrent hematuriain the setting of
nonbacterial prostatitis is relatively uncommon
•antibiotics in addition to standard supportive measures
124Dept of Urology, GRH and KMC, Chennai.

125. HEMATURIA FROM PROSTATE CA
Prostate cancer
•Hematuriatypically results in cases of
significantly locally advanced tumors, often
with bladder base/trigonal invasion.
•Most common local symptom among patients
with advanced symptomatic prostate cancers
•Exclude-hemorrhagiccystitis from radiation
therapy
125Dept of Urology, GRH and KMC, Chennai.

126. HEMATURIA FROM PROSTATE CA
Management
•Primarily with palliative intent
–tumorsare typically invasive of the bladder and/or
pelvic sidewall (T4)
–patients are often elderly and unwell.
•Initial conservative measures
–catheter drainage with or without continuous bladder
irrigation, suffice for most cases of mild prostatic
bleeding.
126Dept of Urology, GRH and KMC, Chennai.

127. HEMATURIA FROM PROSTATE CA
Management
•Palliative external beam radiotherapy
–For patients in whom hematuriais not acutely life
threatening
–patients who are radiation naïve with or without
androgen deprivation therapy may be administered
•Androgen deprivation therapy
–patients who are not candidates for local therapy
–among patients in whom disease has recurred after
previous local therapy
127Dept of Urology, GRH and KMC, Chennai.

128. HEMATURIA FROM PROSTATE CA
Surgery
•Persistent hematuriain the setting of BOO
•Cystoscopy under anesthesiawith fulguration
and/or limited, or channel, transurethral
resection of prostatic tissue should be
undertaken.
128Dept of Urology, GRH and KMC, Chennai.

129. HEMATURIA FROM PROSTATE CA
•Selective angioembolization
–Data on this approach in the setting of prostatic
malignancy are scant and have demonstrated limited
durability of bleeding control
•Urinary diversion
–Initially may be attempted with PCN tube insertion
•Palliative extirpative surgery
–Radical prostatectomy/ cystoprostatectomyand
conduit diversion
–Considered, pending patients’ clinical and comorbidity
status.
129Dept of Urology, GRH and KMC, Chennai.

130. URETHRAL BLEEDING
•Urethral bleeding (urethrorrhagia) is defined
as bleeding emanating from the urethra at a
point distal to the bladder neck, occurring
separate from micturition
•Careful history and physical examination
–blood at the urethral meatus in the absence of
volitional micturition
–initial hematuria
•Implies pathological processes distal to the
external urinary sphincter 130Dept of Urology, GRH and KMC, Chennai.

131. URETHRAL BLEEDING
•Women
–differentiating bleeding from gynecologicorigin
–based on history alone may be challenging
–pelvic examination is typically necessary to clarify
the site of origin
131Dept of Urology, GRH and KMC, Chennai.

132. URETHRAL BLEEDING
Diagnosis
•Retrograde urethrogram
•Cystourethroscopy
–direct visualization permits identification of
pathological processes in the urethra
–biopsy and fulguration allow for histologic
characterization and cessation of bleeding.
132Dept of Urology, GRH and KMC, Chennai.

133. 133Dept of Urology, GRH and KMC, Chennai.

134. URETHRAL BLEEDING
Trauma
•Most common causeof urethral bleeding.
•Example
–blunt trauma via straddle injury, kick to the
perineum, or pelvic fracture
–Foreign body insertion
–Penile fracture
134Dept of Urology, GRH and KMC, Chennai.

135. URETHRAL BLEEDING
Trauma
•Perineal or penile bruising, accompanied by a
hematoma, often is a clear indication of injury
related to trauma.
•Retrograde urethrographyis essential in
instances of trauma when a urethral injury is
suspected
135Dept of Urology, GRH and KMC, Chennai.

136. URETHRAL BLEEDING
Urethritis
•Refers to infection or inflammation of the
epithelial lining of the urethra
•Has been reported secondary to
–bacterial or viral infection
–chemical irritants (i.e., spermicidal jelly),
–Medication related (i.e. amiodarone)
–autoimmune systemic conditions (HLA-B27
reactive arthritis)
136Dept of Urology, GRH and KMC, Chennai.

137. URETHRAL BLEEDING
Urethritis
•Urethral discharge on palpation may be noted
with urethritis in men.
•Urine microscopy and cultures, as well as
urethral swabs for causative organisms,
represent essential components of the
evaluation.
137Dept of Urology, GRH and KMC, Chennai.

138. URETHRAL BLEEDING
•Urethral tumors
–Rare
–blood per meatus may be a manifesting sign
–specifically in men who have undergone a
radical cystectomy with urethra still in situ
•Urethral caruncles
–benignurethral lesions typically originating from the posterior lip of the
urethra
–most commonly found in postmenopausalwomen
–These lesions are thought to arise from prolapse of distal urethra as a
consequence of estrogendeficiency.
•Urethral diverticulum
–classic presentation of dysuria, dyspareunia, and dribbling
–May also report intermittent episodes of bleeding
–urethral discharge may be noted on examination
138Dept of Urology, GRH and KMC, Chennai.

139. HEMATURIA FROM THE UPPER TRACT
•Frequently asymptomatic
•“Clot colic”
–macroscopic bleeding with clots can result in
subsequent ureteral obstruction
•Anemia, and even rarely hemodynamic
instability
•Manifests as total hematuria
•Characterized by wormlike clots passed via the
urethra
139Dept of Urology, GRH and KMC, Chennai.

140. 140Dept of Urology, GRH and KMC, Chennai.

141. MEDICAL RENAL DISEASE
Glomerular diseases
•Constellation of acquired or inherited conditions
in which the glomeruli are damaged.
•Consequences include loss of
–RBCs and protein in the urine
•Clinical sequelae
–Hematuria
–hypoproteinemiawith associated edema
–reduced glomerular filtration rate.
•Urinary findings suggestive of a glomerular cause
–RBC casts in the urinary sediment, dysmorphic RBCs
–proteinuria
141Dept of Urology, GRH and KMC, Chennai.

142. DIAGNOSIS
INVESTIGATION
HISTORY
GLOMERULAR
HEMATURIA
Rash,
arthritis
↑ C3, C4,
ANA
SLE
Hemoptysis
Bleeding
tendency
Microcytic
anemia
Goodpasture
syndrome
Recent URTI or
skin
infection/rash
↑ ASO titer,
C3 level
PSGN
Related to
exercise
+ Renal
biopsy for
IgA, IgG, β1c-
globulin
IgA
nephropathy
(Berger
disease)
Family history
of hematuria
and/or abnUA
Deafness
Alport
nephritis
No other
symptoms/
signs
Renal biopsy
Mesangioproliferati
ve,
mesangiocapillary,
or
Membranous GN
MEDICAL RENAL DISEASE
142Dept of Urology, GRH and KMC, Chennai.

143. MEDICAL RENAL DISEASE
Tubulointerstitialdiseases
•Broadly refer to kidney diseases affecting
structures in the kidney outside the glomerulus.
•Sickle cell nephropathy
–sickled erythrocytes decrease medullary blood flow,
causing local ischemia, microinfarction, and papillary
necrosis
•Analgesic nephropathy
–cause renal papillary necrosis and subsequently
chronic interstitial nephritis
143Dept of Urology, GRH and KMC, Chennai.

144. MEDICAL RENAL DISEASE
Diagnosis and Management
•Percutaneous renal biopsy
–valuable diagnostic modality in case of a suspicion
for glomerular or tubulointerstitialcauses of
hematuria.
•Current guidelines advocate completion of the
hematuriaevaluation even when medical
renal causes are suspected
144Dept of Urology, GRH and KMC, Chennai.

145. VASCULAR CONDITIONS
•Causes:
–Renal AVM, Aneurysm, Nutcracker syndrome
•Predisposing factors
–pelvic or vascular surgery, pelvic irradiation, extensive
ureteral mobilization, and chronic ureteral stenting
•Management
–high mortality rates have been reported with surgical
repairof ureteroiliacfistulas
–angiographic localization with vascular stentinghas
become the current preferred management approach
145Dept of Urology, GRH and KMC, Chennai.

146. VASCULAR CONDITIONS
Renal arteriovenous malformations (AVMs)
•Abnormal communications between
intrarenal arterial and venous systems
•Causes
–congenital and acquired (iatrogenic)
•Acquired AVMs
–account for 75% of such cases
–associated with renal biopsy, renal surgery (partial
nephrectomy, nephrolithotomy), and trauma
146Dept of Urology, GRH and KMC, Chennai.

147. VASCULAR CONDITIONS
Renal arteriovenous malformations (AVMs)
•Arteriography with selective angioembolization
–primary diagnostic and therapeutic option
–afford symptom resolution with maximal preservation
of functional renal parenchyma.
–Thus expeditious angiography should be considered
for patients with a recent history of a renal procedure
presenting with GH.
–The goal of AVM embolization is occlusion of the site
where abnormal arterial and venous communication
exists
147Dept of Urology, GRH and KMC, Chennai.

148. VASCULAR CONDITIONS
Renal artery aneurysms
•May be related to connective tissue disorders
•Generally asymptomatic.
–Hypertension may be present in up to 90% of affected
persons
–Dissecting aneurysms may cause flank pain with GH
•Management
–initially with blood pressure control
–subsequently via endovascular approaches in the
refractory albeit hemodynamically stable patient
–surgical intervention is typically necessary in the unstable
patient
148Dept of Urology, GRH and KMC, Chennai.

149. VASCULAR CONDITIONS
•“Nutcracker phenomenon”
–compression of the left renal vein between the
aorta and superior mesenteric artery
149Dept of Urology, GRH and KMC, Chennai.

150. VASCULAR CONDITIONS
Haematuria
Blood enters collecting system
Small-volume rupture of thin-walled capillaries into the collecting system
Increase in left renal vein pressure
Compression of left renal vein
“Nutcracker syndrome”
150Dept of Urology, GRH and KMC, Chennai.

151. VASCULAR CONDITIONS
“Nutcracker syndrome”
•Management
–Surgery: Left renal vein transposition, superior
mesenteric artery transposition, and nephrectomy
–Endovascular stenting to maintain a patent renal
vein has been reported as well.
151Dept of Urology, GRH and KMC, Chennai.

152. LATERALIZING ESSENTIAL HEMATURIA
•Also termed benign essential hematuriaor
chronic unilateral essential hematuria
•Defined as macroscopic hematuria
cystoscopicallylocalized to one side of the
urinary system without a clear identifiable
cause
152Dept of Urology, GRH and KMC, Chennai.

153. LATERALIZING ESSENTIAL HEMATURIA
•As such, patients have typically had normal
prior radiographic studies.
•Although rare, may range from minimally
symptomatic GH to clot retention and anemia
•Many such cases no identifiable cause can be
determined
153Dept of Urology, GRH and KMC, Chennai.

154. LATERALIZING ESSENTIAL HEMATURIA
•Cystoscopy
–at the time of bleeding may allow lateralization of
the source of hematuria.
•Ureteropyeloscopy
–in the absence of a clear cause for bleeding
localized to the upper tract
–recommended as a diagnostic and potentially
therapeutic modality
154Dept of Urology, GRH and KMC, Chennai.

155. LATERALIZING ESSENTIAL HEMATURIA
Critical components of diagnostic ureteropyeloscopy
include
•the judicious use of guidewires(to avoid inadvertent
urothelial injury),
•low-pressure irrigation
•systematic evaluation of all calices from a superior to-
inferior approach
•Biopsysamples can be obtained for lesions suspicious
for malignancy
•fulgurationof such tumorsor other noted sources of
bleeding (i.e., hemangioma) can be accomplished as
well.
155Dept of Urology, GRH and KMC, Chennai.

156. THANK YOU