Surgical Aspects of Hematuria - Dr. Sattwik Acharya.pptx

This PDF presentation, prepared by Dr. Sattwik Acharya (PGY-1, Dept. of General Surgery, MKCG MCH, Brahmapur), provides a comprehensive overview of hematuria—the presence of blood in urine. Drawing primarily from Campbell-Walsh-Wein Urology (12th ed.) and Bailey & Love’s Surgery (28th ed.), it systematically covers:
Definition and Classification — Differentiating gross vs. microscopic and glomerular vs. non-glomerular hematuria.
Etiology — Including medical, surgical, infectious, neoplastic, traumatic, and iatrogenic causes across all levels of the urinary tract.
Diagnostic Evaluation — Detailing history, examination, urinalysis, cytology, imaging (USG, CTU, MRI), and cystoscopy indications.
Site-specific Discussions — Explaining hematuria originating from the kidneys, bladder, prostate, and urethra, with characteristic clinical features, investigations, and management strategies.
Clinical Algorithms — Simplified flowcharts for risk stratification and investigation based on presentation and age group.
Overall, it serves as a concise, evidence-based teaching resource for medical students and residents for understanding the evaluation and differential diagnosis of hematuria.

1. HEMATURIA Dr. Sattwik Acharya PGY-1 Resident Dept. of General Surgery MKCG MCH, Brahmapur

2. Table of contents 01 04 02 03 Definition Classification Evaluation of hematuria Gross Hematuria Based on Origin

3. Definition Hematuria refers to presence of blood in urine. It is primarily classified as Gross hematuria and Microscopic hematuria . It is one of the most common indications for urology evaluation and is recognized as a sign of potentially important illness. Ref.: Bailey & Love, 28th ed., Ch. 81: Genitourinary, p. 1448 Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 1, p. 3; Ch. 9, p. 183

4. Glomerular Hematuria Non-glomerular Hematuria Medical/Non-Surgical Surgical Based on pathology: Based on clinical features: Classification Microscopic Hematuria (Not visible to naked eye) Gross Hematuria (Visible to naked eye)

5. Glomerular Hematuria Suggested by the presence of dysmorphic erythrocytes, RBC casts, proteinuria and brown or cola- colored urine. Originates from the kidney’s glomeruli. Urinalysis Findings: Dysmorphic RBCs: Irregularly shaped red blood cells. RBC Casts: Indicate bleeding within the nephron. IgA Nephropathy (Berger’s Disease): Most common cause; often follows upper respiratory infections commonly in children and young adults. Post-infectious Glomerulonephritis: Typically occurs after streptococcal infections. Alport Syndrome: Hereditary nephritis associated with hearing loss. Lupus Nephritis: Associated with systemic lupus erythematosus. Henoch- Schönlein Purpura: Vasculitis affecting the kidneys. Thin Basement Membrane Disease: Benign familial hematuria . Causes: Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 1, p. 15 Renal biopsy is necessary to establish the precise diagnosis.

6. Non Glomerular Hematuria (Medical/ Non-Surgical Hematuria) A. Medical/Non-Surgical: Presence of circular erythrocytes and absence of RBC casts, associated with significant proteinuria. Bleeding tendencies Renal cystic disease Papillary necrosis in diabetics and suspected analgesic abusers Excessive Anticoagulants (above normal therapeutic levels) Exercise induced (>10 km): disappears at rest, usually originating from bladder Vascular disease: Renal artery embolism & thrombosis, AV fistula, Renal vein thrombosis Causes: Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 1, p. 15

7. Non Glomerular Hematuria (Surgical Hematuria) A. Surgical: Presence of circular erythrocytes, absence of RBC casts + absence of significant proteinuria. Urologic tumors Stones BPH UTI Causes: Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 1, p. 16

8. Microscopic Hematuria Definition: American Urological Association (AUA) defines it as presence of 3 or more RBCs/HPF on a single urine analysis. Neoplasms: Bladder, Ureteral, Renal Cortical Tumor , Prostate Cancer, Urethral Cancer Infection: Cytitis , Pyelonephritis, Urethritis, TB, Schistosomiasis, Hemorrhagic Cystitis Calculus: Nephroureterolithiasis , Bladder calculus BPH Medical Renal Disease: Nephritis, IgA Nephropathy Congenital/Acquired anatomic abnormality: Polycystic Kidney Disease, Ureteropelvic junction obstruction, Ureteral stricture, Urethral diverticulum, Fistula Other: Exercise induced, Hematologic disorder, Papillary necrosis, Renal Vein thrombosis, Trauma, Recent GU surgery or instrumentation Causes: Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 184

9. Gross Hematuria CLASSIFICATION BASED ON OCCURRENCE DURING VOIDING Initial Hematuria Terminal Hematuria Total Hematuria Occurs at the beginning of micturition and clear by the end of micturition. Passage of blood or clots in urine during the last part of micturition Passage of blood or clots through the entire of micturition Typically suggests urethral damage Suggests damage to bladder neck, bladder trigone or prostate Suggests damage to the bladder, ureters or kidneys Frank hematuria or macrohematuria or visible hematuria . Hematuria that can be seen through naked eye. Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 183

10. Gross Hematuria Gross Hematuria must be distinguished from: Through eliciting a proper menstrual history Obtaining a catheterized specimen Vaginal bleeding Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 183 Endogenous sources: Bilirubin, myoglobin Foods ingested: Beets, black berries Drugs: Phenazopyridine, rifampicin Dehydration Pigmenturia

11. Gross Hematuria Etiology : Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 188 Bladder cancer (most common in adults >50 years) Renal cell carcinoma Upper tract urothelial carcinoma (UTUC) Prostate cancer Urethral carcinoma 1. Malignancy (must always be ruled out) Urinary tract infection (UTI) Pyelonephritis Tuberculosis (renal) Schistosomiasis (especially in endemic areas) 2. Infectious Causes Stones anywhere in the tract (kidney, ureter, bladder) Often associated with pain, but can be painless 3. Urolithiasis (Stones)

12. Gross Hematuria Etiology : Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 188 External injury (blunt or penetrating) Iatrogenic (post-procedural, catheterization, biopsies, etc.) 4. Trauma Common in elderly males Can cause spontaneous or post-exertional hematuria 5. Benign Prostatic Hyperplasia (BPH) Anticoagulation or coagulopathy Radiation cystitis Exercise-induced Endometriosis (vesical or ureteral involvement) 6. Other Causes

13. Evaluation of Hematuria 1. History Age and gender Smoking history (risk for urothelial cancer) History of trauma Occurrence during voiding – initial/terminal/total (location of damage in the urinary tract e.g., urethra, bladder, kidneys) Irritative voiding symptoms (e.g., urgency, frequency – cystitis) Flank pain (stones, obstruction) Medication use (e.g., anticoagulants, cyclophosphamide) Occupational exposures (aromatic amines) Family history (e.g., Alport syndrome, polycystic kidney disease) 2. Clinical Examination General Examination: To detect any other bleeding sites and systemic effects of blood loss, e.g. pallor, tachycardia, hypotension Abdominal Examination: For renal masses and flank tenderness DRE: For prostate evaluation

14. Diagnostic Evaluation of Hematuria Initial Considerations Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 1, p. 14 Before proceeding with diagnostic evaluation, rule out: - Pseudohematuria (e.g. beeturia , medications like rifampicin, phenazopyridine) - Contamination (menstrual blood, improper collection) - Transient hematuria (seen after exercise, trauma, or fever) Urinalysis with microscopy is the cornerstone. Dipstick positive result should be confirmed with microscopic examination of urine. False positives (myoglobin, hemoglobin , oxidizing agents) and false negatives (vitamin C, dilute urine) must be ruled out. Interpretation of urinalysis should be done with clinical history. Hematuria needs to be distinguished from hemoglobinuria and myoglobinuria by microscopic examination of the centrifuged urine: Hematuria: presence of a large number of RBCs in urine. If absent, examination of centrifuged blood sample:- - Hemoglobinuria : supernatant will be pink - Myoglobinuria: serum remains clear

15. Urine Dipstick

16. Diagnostic Evaluation of Hematuria Urine Microscopy: Dysmorphic RBCs/ RBC Casts ± Proteinuria: Glomerular pathology Isomorphic RBCs: Non-glomerular pathology (+) Proteinuria: Medical Non-glomerular Hematuria (-) Proteinuria: Surgical Non-glomerular Hematuria Urine Culture: To rule out UTI as a cause. Repeat Urine Analysis post-treatment if positive. Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 1, p. 14

17. Diagnostic Evaluation of Hematuria Urine Cytology Considered in patients >35 years or with risk factors (smoking, industrial exposures). Detects high-grade urothelial carcinoma Not sensitive for low-grade tumors Negative result does not rule out malignancy Other Lab Investigations CBC: to check for anemia, infection. RFT (Sr. Urea, Sr. Creatinine): to assess renal function. Coagulation profile: to rule out bleeding diathesis. PSA: to rule out prostate cancer Serologies (if glomerular disease suspected): ANA, complements, ASO, anti-GBM. Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 1, p. 16

18. Imaging Studies 1. Ultrasound (USG) First-line in many settings (esp. in young, pregnant or those with renal impairment) Detects renal cysts, masses, hydronephrosis, stones Limitations: Poor visualisation of ureters and bladder wall, may miss small renal or urothelial cancers 2. CT Urography (CTU) Evaluates kidney, ureters, bladder Gold Standard for upper tract evaluation in gross hematuria and persistent microscopic hematuria in high risk patients. Detects urothelial carcinoma, renal tumors and obstruction with high sensitivity Triple-phase protocol: Non contrast: Detects stones, calcifications, hemorrhage Nephrogenic: To evaluate renal parenchyma for masses Excretory: To visualise the urothelium (collecting system, ureters, bladder) 3. MRI/MR Urography Used when renal impairment (GFR < 30)/contrast allergy is present or in pediatric cases or radiation avoidance No radiation but lower sensitivity than CT for small urothelial tumors

19. Cystoscopy Essential for Lower Urinary Tract Evaluation Should be done in all patients with: Gross hematuria , irrespective of age Age > 35 years with microscopic hematuria Risk factors for bladder cancer Allows direct visualization of: Bladder mucosa ( tumors , stones, cystitis) Bladder neck and urethra (strictures, prostratic bleeding) Can detect carcinoma in situ (CIS) and flat lesions missed by imaging

20. When to Use Each Investigation? Clinical Clue Likely Source Next Step RBC Casts, proteinuria Glomerular Serology, Nephrology referral Painful hematuria , colic Stone disease NCCT KUB Painless gross hematuria in smoker > 50 years Bladder/Urothelial Ca CT Urogram + Cystoscopy Recent infection, fever UTI or prostatitis Urine culture, Antibiotics History of trauma Renal parenchyma CT Abdomen/Pelvis In gross hematuria : Urine Analysis + Urine Culture CBC, RFT CT Urogram Cystoscopy In asymptomatic microscopic hematuria : Urine Analysis to confirm Low Risk: Monitor Intermediate/High Risk: Imaging + Cystoscopy

21. Algorithm for Evaluation of Hematuria Confirm hematuria on microscopy Stratify Risk (age, smoking, symptoms) Evaluate: Low Risk (age < 35, no smoking h/o, no symptoms): Repeat Urine Analysis, consider USG Intermediate Risk (age 35-50 or mild symptoms): USG or CT Urogram ± Cystoscopy (if needed) High Risk (age > 50, smoker, occupational exposure) – gross hematuria or persistent microscopic hematuria : Full workup with CT Urogram + Cystoscopy + Cytology Refer to Nephrology if glomerular cause is suspected Follow-up and surveillance for idiopathic microscopic hematuria Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9

22. 4. Urethra 1. Upper urinary tract 3. Prostate 2. Urinary bladder Gross Hematuria Based on Origin

23. Hematuria Originating from the Upper Urinary Tract Causes: Hematuria originating from Kidney or Ureters Can be Asymptomatic Microscopic Hematuria (AMH) and gross hematuria Usually characterized by worm-like clots past per urethra. Nephrolithiasis Glomerular disease (IgA Nephropathy, Thin BM Disease) Polycystic Kidney Disease Infection (Pyelonephritis, Renal TB) Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 193 Vascular Causes Arteriovenous Malformations Renal Artery and Vein thrombosis Vasculitis (HSP, Wegener’s) Upper tract urothelial carcinoma (UTUC) Renal Cell Carcinoma (RCC) Benign Causes Malignant Causes Other Causes Trauma Obstruction (Ureteropelvic junction, Ureteral)

24. Hematuria Originating from the Upper Urinary Tract Diagnosis: Urinalysis: dysmorphic RBCs/RBC casts: glomerular origin Urine culture: to rule out infection (pyelonephritis, TB) Imaging: CT Urogram : Gold Standard: can identify urothelial tumors , renal masses, stones and vascular anomalies MR Urography: if CT is contraindicated or young patients or pregnant females Ultrasound: Cystic lesions, Hydronephrosis, Parenchymal abnormalities Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 194 Ureteroscopy: Direct visualisation of ureter and renal pelvis Biopsy of suspicious lesions

25. Hematuria Originating from Urinary Bladder Characterized by diffuse inflammation and bleeding from the bladder mucosa Causes: Infections: Bacterial, Viral (BK virus, adenovirus), Fungal, Parasitic Trauma: External, Post-surgical (e.g. transurethral resection of bladder) Malignancy Chemical exposure: Aniline dye, Ether Radiation therapy history: Prostate Ca, Cervical Ca Drug induced: Oxazaphosphorine class of chemotherapeutic agents (Cyclophosphamide, Ifosfamide ), Bleomycin, Allopurinol Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 188

26. Hematuria Originating from Urinary Bladder Hematuria (can be microscopic to gross) Dysuria Increased frequency and urgency Lower abdominal pain Diagnosis: Urinalysis Urine cultures USG or CT Urogram (to assess bladder wall thickness and rule out other pathologies) Cystoscopy (direct visualization of bladder mucosa to identify bleeding sites, ulcers or tumors ) Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 189 Clinical Features:

27. Hematuria Originating from Urinary Bladder Supportive Care: Hydration to flush out irritants, Pain management.  Bladder Irrigation: Continuous bladder irrigation (CBI) with saline to prevent clot formation and maintain catheter patency.  Management: General Measures: Chemotherapy-induced HC: Mesna : A uroprotective agent that binds toxic metabolites of cyclophosphamide and ifosfamide , preventing bladder damage. Hyperhydration: Ensures rapid excretion of toxic metabolites.  Radiation-induced HC: Hyperbaric Oxygen Therapy (HBOT): Promotes healing of irradiated tissues by enhancing oxygen delivery. Studies have shown significant improvement in bladder mucosal health after 30 to 40 sessions of HBOT . Specific Treatments: Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 189-190

28. Hematuria Originating from Urinary Bladder Management: Intravesical Therapies: Alum irrigation: Acts as an astringent to reduce bleeding. Formalin instillation: Used in refractory cases to cauterize bleeding vessels. Hyaluronic acid: Restores the glycosaminoglycan layer of the bladder mucosa. Infectious HC: Antiviral therapy if a specific viral cause is identified.  Surgical Interventions: Reserved for severe cases unresponsive to conservative measures. Options include cystoscopic coagulation, urinary diversion or cystectomy. Specific Treatments: Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 189-190

29. Hematuria from Prostate Etiology Mechanism Clinical Features Management BPH Increased vascularity and friability of enlarged prostate may lead to bleeding Often LUTS such as frequency, urgency, weak stream. Medical: Alpha-blockers, 5-alpha-reductase inhibitors Surgical: TURP or laser therapies Prostatitis Inflammation leading to mucosal irritation and bleeding Dysuria, pelvic pain, fever Antibiotics Analgesics Prostate Ca Tumor invasion into prostatic urethra or adjacent structures causes bleeding Often asymptomatic in early stages; hematuria may indicate advanced disease Localised: Active surveillance, surgery or radiation therapy Advanced: Hormonal therapy, Chemotherapy Post-procedural (Biopsy, TURP, Catheterization) Instrumentation-induced trauma leading to bleeding Continuous bladder irrigation or endoscopic management if bleeding persists Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 190-192

30. Hematuria from Urethra Iatrogenic: Catheterization, cystoscopy or surgical interventions. External Trauma: Perineal or pelvic injuries (straddle injury, kick to perineum) Causes: Traumatic Causes: Urethritis: Often due to sexually transmitted infections (e.g., Neisseria gonorrhoeae, Chlamydia trachomatis). Infectious Causes: Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 192-193 Urothelial Carcinoma Squamous Cell Carcinoma (meatus/glans) Neoplastic Causes: Strictures: Narrowing of the urethra leading to mucosal irritation. Urethral Polyps or Caruncles: Benign lesions, especially in postmenopausal women. Inflammatory and Other Causes:

31. Hematuria from Urethra Initial Hematuria Terminal Hematuria: May suggest prostatic urethra involvement Urethrorrhagia: Bleeding not associated with urination, commonly seen in prepubertal boys (usually benign and self limiting) Clinical Features: Urinalysis Urine Culture Retrograde Urethrography: If urethral injury is suspected Cystourethroscopy: To visualise the urethra and bladder if bleeding persists or the cause is unclear Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 192-193 Diagnosis:

32. Hematuria from Urethra Trauma-related bleeding: Stabilise the patient and control bleeding, surgical intervention may be required Infectious Causes: Antibiotics Neoplastic Causes: Surgery, RT or CT depending on evaluation Benign lesions: Observation or surgical excision if symptomatic Idiopathic urethrorrhagia in children: Often requires no treatment, reassurance and observation. Management: Ref.: Campbell-Walsh-Wein, Urology, 12th ed., Vol 1, Ch. 9, p. 192-193

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