Haematuria

Dr. Abdelmoniem E. Eltraifi

Consultant Urologist

College of Medicine & KKUH King Saud University, Riyadh, Kingdom of Saudi Arabia

Cases Quiz

Case 1

 42 years old male, under your follow up for DM. During his routine follow up appointment. Told you that:

 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.

Haematuria

Prevalence of Haematuria ranges from

2.5% to 20%

Haematuria classified into:

1.

2.

Gross, Macroscopic Symptomatic

( Painful) or

Asymptomatic

( painless)

Microscopic, invisible A lso Symptomatic

( Painful) or

Asymptomatic

( painless)

Microscopic

:

3 or more RBCS /High power, in 2 out of 3 properly collected samples ( AUA).



P revalence ranges from 0.19% to 16.1%.

 

Neoplasm of genitourinary tract (GU) found in about 3-5% of asymptomatic patients.

No identifiable cause in about 40%.

Gross ( Macroscopic, Visible, Clinical):

1 ml of blood in 1 liter of urine is visible for the patients.



22 to 40% of patients presented with asymptomatic gross haematuria are found to harbor GU neoplasm.

Causes of Haematuria

Varies according to:

 Patient Age  Type: Gross or Microscopic  Symptomatic or Asymptomatic  The existence of risk factors for malignancy.

Causes of Haematuria…

Urinary tract malignancy

 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

Causes of Haematuria…

Anatomic abnormalities

 Arteriovenous malformation  Urothelial stricture disease  Ureteropelvic junction obstruction  Vesicoureteral reflux  Nutcracker syndrome

Causes of Haematuria…

Medical or renal disease

 Glomerulonephritis  Interstitial nephritis  Papillary necrosis  Alport syndrome  Renal artery stenosis

Causes of Haematuria…

Metabolic disorders

 Coagulation abnormalities  Hypercalciuria  Hyperuricosuria

Causes of Haematuria…

Miscellaneous

 Trauma  Exercise-induced hematuria   Benign familial haematuria Loin pain –haematuria syndrome

Causes of Red-Orange urine discoloration

Color

Red/Brown Orange

Foods

Beets Blackberries Rhubarb Fava beans Aloe Carotene containin g foods (eg, carrots, winter squash)

Drugs

Laxatives (eg, Ex Lax, phenolphthalein) Tranquilizers (eg, chlorpromazine, thioridazine, propofol Beta-carotene supplements Vitamin B supplements Warfarin Rifampin Pyridium

Others

Porphyrin (eg, lead, mercury poisoning) Globins (eg, hemoglobin, myoglobin) Urochrome (eg, dehydration)

Red colored candy and drinks

Transient Microscopic Haematuria could be due to :

      Vigorous Exercise Sexual Intercourse Viral infection UTI Mild Trauma Menstrual Contamination

Risk factors for Urothelial cancer in patients with microscopic haematuria



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



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 Red Colored food or drinks intake.

Menses, Exercise, Sexual intercourse ( Transient Microscopic).



Smoking

( Gross haematuria mandate full urological work up).



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

 For young women with microscopic haematuria, symptoms and urinary finding of UTI just do: 1.

2.

3.

Urine culture Treat UTI 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 If there in risk for GU neoplasm Nephrology Evaluation Urology Evaluation

Urologic Evaluation of Asymptomatic Microscopic Haematuria Follow up by 1.

Measuring BP.

2.

3.

4.

MSU.

Urine Cytology.

U & E.

Lap Investigations

 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:

 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

 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:

 MSU, obscured by RBCs.

 Hb was 11 gram/L.

 INR was 2.5.

This patient needs:

 To look after Coagulation problem.

 Insertion of 3 ways urethral catheter to irrigate her bladder.

 Urological investigation work up.

Case 3



A 60-year-old woman is referred to the emergency department (ED) because of a recent event of painless macroscopic haematuria.



No Other positive points in her history

On physical examination:

 No abnormality detected.

A laboratory analysis including

:  MSU: uncontable RBCs.

urine culture: No growth.



Urine cytology is positive for malignant cells

.  CBC, U&E, LFT: all within normal  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 .

Which of the following examinations is today regarded as being the imaging modality of choice for such patients?

1.

2.

3.

4.

Intravenous urography (IVU) Computed tomography (CT) urography Abdominal ultrasonography Abdominal magnetic resonance imaging (MRI)

What is the diagnosis?

Hint: Look for differences between the right and left kidneys

1.

2.

3.

4.

Renal stone Urothelial carcinoma External renal compression Complicated renal cyst

Which of the following statements is NOT true?

1.

2.

3.

4.

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.