Transcript Haematuria.ppt

Haematuria
Dr. Abdelmoniem E. Eltraifi
Consultant Urologist
College of Medicine & KKUH
King Saud University, Riyadh, Kingdom of Saudi Arabia
Cases Quiz
Case 1
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42 years old male, under your follow up for
DM. During his routine follow up
appointment. Told you that:
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He had an episode of gross haematuria, one
month ago. He want to a private clinic near
his house.
 They gave him an IV fluids.
 They did for him: MSU and urine culture,
which he showed to you, with only +ve
uncountable RBCs.
• An US of kidneys, bladder and Pelvis
and all were normal
Following that single episode, he had a clear urine.
His history other wise unremarkable apart from DM
What you will do for him?
Reassurance.
 Follow up.
 Further work up.
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What will you do First?
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Urine analysis.
Other Investigations.
If his urine analysis came clear, with nil RBCs
Will you do:
 Reassurance
 Follow up?
 Further investigations?
What investigations?
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Urine Cytology
 Repeat US of the kidneys and pelvis.
 IVU
 CTU
If CTU and urine cytology were –ve.
Are you going to do:
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Further investigations?
 Follow up?
 Reassurance?
What investigation and why?
Haematuria
Prevalence of Haematuria ranges from
2.5% to 20%
Haematuria classified into:
1.
Gross, Macroscopic
Symptomatic ( Painful) or Asymptomatic ( painless)
2.
Microscopic, invisible
Also Symptomatic ( Painful) or Asymptomatic ( painless)
Microscopic:
3 or more RBCS/High power, in 2 out of 3
properly collected samples ( AUA).
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Prevalence ranges from 0.19% to 16.1%.
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Neoplasm of genitourinary tract (GU) found in
about 3-5% of asymptomatic patients.
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No identifiable cause in about 40%.
Gross ( Macroscopic, Visible, Clinical):
1 ml of blood in 1 liter of urine is
visible for the patients.
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22 to 40% of patients presented with
asymptomatic gross haematuria are
found to harbor GU neoplasm.
Causes of Haematuria
Varies according to:
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Patient Age
Type: Gross or Microscopic
Symptomatic or Asymptomatic
The existence of risk factors for malignancy.
Causes of Haematuria…
Urinary tract malignancy
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Urothelial cancer
 Renal cancer
 Prostate cancer
Causes of Haematuria…
Urinary tract infection
 Urinary calculi
 Benign prostatic hyperplasia
 Radiation cystitis and/or nephritis
 Endometriosis & Vesico-Uterine Fistula
 Urethral polyps
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Causes of Haematuria…
Anatomic abnormalities
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Arteriovenous malformation
Urothelial stricture disease
Ureteropelvic junction obstruction
Vesicoureteral reflux
Nutcracker syndrome
Causes of Haematuria…
Medical or renal disease
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Glomerulonephritis
Interstitial nephritis
Papillary necrosis
Alport syndrome
Renal artery stenosis
Causes of Haematuria…
Metabolic disorders
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Coagulation abnormalities
 Hypercalciuria
 Hyperuricosuria
Causes of Haematuria…
Miscellaneous
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Trauma
 Exercise-induced hematuria
 Benign familial haematuria
 Loin pain–haematuria syndrome
Causes of Red-Orange urine discoloration
Color
Foods
Drugs
Others
Red/Brown
Beets
Blackberries
Rhubarb
Fava beans
Aloe
Laxatives (eg, ExLax,
phenolphthalein)
Tranquilizers (eg,
chlorpromazine,
thioridazine,
propofol
Porphyrin (eg,
lead,
mercury
poisoning)
Globins (eg,
hemoglobin,
myoglobin)
Orange
Carotene containing
Beta-carotene
supplements
Vitamin B
supplements
Warfarin
Rifampin
Pyridium
Urochrome (eg,
dehydration)
foods
(eg, carrots,
winter squash)
Red colored candy and drinks
Transient Microscopic Haematuria could be due to:
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Vigorous Exercise
Sexual Intercourse
Viral infection
UTI
Mild Trauma
Menstrual Contamination
Risk factors for Urothelial cancer in
patients with microscopic haematuria
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Smoking history
 Occupational exposure to chemicals or dyes
(benzenes or aromatic amines)
 History of gross haematuria
 Age greater than 40 years
 History of urologic disorder or disease
 History of irritative voiding symptoms
 History of urinary tract infection
 Analgesic abuse ( Phenacetin)
 History of pelvic irradiation.
Haematuria Patients Work Up
History
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Age
Residency.
Occupation
Duration. Episodes, Urine color darkness
Painless or painful
Timing of haematuria
Clots and shape of clots
Trauma
Bleeding from other sites
Associated Symptoms urinary and Systemic
History of :Bleeding disorders, SC, TB, Bilharzias & stone disease.
Family History of : Malignancy, hematological disorders, renal
diseases
Drugs
Colored food or drinks intake.
Menses, Exercise, Sexual intercourse ( Transient Microscopic).
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Smoking
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( Gross haematuria mandate full urological work up).
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Asymptomatic microscopic haematuria in
children does not mandate aggressive evaluation
other than long-term follow-up, whereas it is
important to evaluate asymptomatic gross
haematuria
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For young women with microscopic
haematuria, symptoms and urinary finding
of UTI just do:
1. Urine culture
2. Treat UTI
3. Repeat MSU 6 weeks after treatment
4. No need for further work up
Initial Evaluation of Asymptomatic
Microscopic Haematuria
Exclude Benign transient causes
Menses, vigorous exercise, trauma, sexual activity, viral illness,
infection
If one or more of the following present:
Proteinuria, Dysmorphic RBCs, Red
cells cast, Elevated creatinine
Nephrology Evaluation
If there in risk for GU
neoplasm
Urology Evaluation
Urologic Evaluation of Asymptomatic Microscopic Haematuria
Follow up by
1.
Measuring BP.
2.
MSU.
3.
Urine Cytology.
4.
U & E.
Lap Investigations
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MSU
 Urine Culture ( Pyogenic Organisms).
 Urine FOR AFB ( Tuberculosis).
 Urine Cytology and Tumor markers
 CBC & Hematology
 U&E
 LFT
Radiology
US
US
US
IVU
CT Urography
CT Urography
CT Urography
CT Urography
CT Urography
CT Urography
CT Urography
When to refer to urologist:
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If there is a positive findings, that requires
urological intervention
 If the patient is high risk for GU neoplasm, with
no findings in the lap and radiology work up.
Cystoscopy
Cystoscopy
Cystoscopy
Angiography
Angiography
Angiography
Angiography
Ureteroscopy
Ureteroscopy
Case 2
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66 years old female patient on Warfarin for
a history of DVT, presented to the
emergency room with gross haematuria.
 No abnormal sign on clinical examination.
Her investigations:
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MSU, obscured by RBCs.
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Hb was 11 gram/L.
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INR was 2.5.
This patient needs:
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To look after Coagulation problem.
 Insertion of 3 ways urethral catheter to
irrigate her bladder.
 Urological investigation work up.
Case 3
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A 60-year-old woman is referred to the emergency department (ED) because of a
recent event of painless macroscopic haematuria.
She reports having experienced several similar episodes during the past year, all of
which resolved spontaneously. She regards these episodes as being of gynecologic origin
because she is 5 years postmenopausal.
She describes a general feeling of malaise in the days preceding the current episode,
But she denies having any fever, dysuria, or increased frequency or urgency of
urination.
The patient also describes an unintentional weight loss of 5 kg during the past 2 years.
The patient's previous medical history includes hypothyroidism that was treated
medically with thyroxin.
And her surgical history includes 2 treatments of dilatation and curettage (D&C) and a
tonsillectomy.
She denies smoking, drug use, or alcohol consumption. She has no previous history of
kidney stones or recurrent urinary tract infections.
On physical examination:
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the patient appears well.
She has a temperature of 98.8°F (37.1°C),
A pulse rate of 71 bpm, and a blood pressure of 150/86 mm Hg.
The head and neck examination is normal.
Lung auscultation reveals normal breath sounds bilaterally, without wheezing
or crackles.
Her heart sounds are regular, with a 2/6 systolic murmur maximally
auscultated over the right second intercostal space.
The abdomen is non distended and non tender, no masses are palpated, and
there are no signs of peritoneal irritation.
No peripheral edema is noticed,
Peripheral pulses are palpated, and the neurologic examination is normal.
A gynecologic evaluation that includes a speculum examination and
transvaginal ultrasonography is performed, which reveals no pathologic
findings.
A laboratory analysis including:
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A complete blood cell (CBC) count, coagulation studies,
and a basic metabolic panel, shows a normal hemoglobin
level, normal platelet count, and no coagulopathy.
No electrolyte abnormalities are present.
A urine culture is negative.
Urine cytology is positive for malignant cells.
Cystoscopy is performed, which demonstrates a normal
urethra leading to a urinary bladder covered by normal
mucosa, with no exophytic lesions and no active bleeding.
What is the diagnosis?
Hint: Look for differences between the right and left kidneys
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Renal stone
 Urothelial carcinoma
 External renal compression
 Complicated renal cyst
Which of the following examinations is today regarded as being the
imaging modality of choice for the diagnosis of upper-tract lesions?
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Intravenous urography (IVU)
 Computed tomography (CT) urography
 Abdominal ultrasonography
 Abdominal magnetic resonance imaging (MRI)
Which of the following statements is NOT true?
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Men are twice as likely as women to develop an upper-tract tumor.
Upper-tract tumors rarely present before the age of 40 years.
Disease-specific annual mortality is greater in men than in women.
Upper-tract Urothelial carcinoma accounts for 5-7% of all renal tumors.