Download - Hematuria
HEMATURIA
BYDR.MOHAMED ASHRAF MOSTAFA
MS.FRCS
HEMATURIA• Definition : presence of blood in the urine.• The passage of blood in the urine is
always alarming and investigation is warranted.
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.
TYPES OF HEMATURIA
MACROSCOPIC (Gross)
MICROSCOPIC: SYMPTOMATIC ASYMPTOMATIC(with (proteinuria or isolated)
INITIALTERMINAL
TOTAL
CAUSES OF HEMATURIA
MEDICAL
UROLOGICAL
MEDICAL CAUSES OF HEMATURIA
NephrologicalIg nephropathy, post
Infectious g.n.Less commonly,membrano-proliferative g.n.,H.S.purp
Coagulationdisorders, hemophilia
anticoagulants.S.C.disease, renal pap.
necrosis, vascular disease,emboli to kidney
UROLOGICAL CAUSESCANCER: 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 malformationsBPH
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 orMenstrual contamination.
DIAGNOSIS OF HEMATURIAHISTORY
• 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.
COMMON CAUSES OF HEMATURIA BYAGE& SEX
• 0-20 yr : Acute glomerulonephritis Acute UTI Congenital UT anomalies with obstruction• 20-40 yr Acute UTI Stones Bladder cancer
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
Risk Factors for Significant Disease in Patients with Microscopic Hematuria
Smoking historyOccupational exposure to chemicals or dyes (benzenes or aromatic amines)History of gross hematuriaAge >40 yearsHistory of urologic disorder or disease
DIAGNOSTIC APPROACH OF HEMATURIAPHYSICAL 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.
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.
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.(
LABORATORY STUDIES
Urine microscopyFresh specimen:
Pyuria suggests infection/inflammation. RBC casts suggest GN .
Dysmorphic RBC suggests renal origin
Urine c/s
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
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.
IMAGING STUDIES
Renal and bladder ultrasonographySpiral CTVoiding cystourethrographyRadionuclide studies
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,
CT SCAN
INTRAVENOUS UROGRAPHY
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
VOIDING CYSTOURETHROGRAPHY
Congenital abnormalities of UT
CYSTOSCOPY
Recommended for higher risk patients.
If find lower tract disease on cystoscopy , the upper tracts should also be evaluated
RENAL BIOPSY
Rarely indicated in the evaluation of isolated asymptomatic hematuria.
Relative indications are as follows: 1.Significant proteinuria2.Abnormal renal function
3.Recurrent persistent hematuria4.Serologic abnormalities (abnormal complement,
ANA, or dsDNA levels)5.Recurrent gross hematuria
6.A family history of end-stage renal disease
Peditric
Adult patient with asymtomatic mic. Hematuria
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
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)
THANK YOU