HaematuriaHaematuria

Marc Laniado MD FRCS(Urol) FEBUMarc Laniado MD FRCS(Urol) FEBU

www.windsorurology.co.uk

Types of HaematuriaTypes of Haematuria

Visible or non visibleVisible or non visible

Symptomatic or asymptomaticSymptomatic or asymptomatic

Symptomatic v AsymptomaticSymptomatic v Asymptomatic

Symptomatic means haematuria Symptomatic means haematuria associated with lower or upper urinary associated with lower or upper urinary tract symptomstract symptoms

Visible haematuria or coloured urine?Visible haematuria or coloured urine?

Yellow-orangeYellow-orange RifampicinRifampicin

Brown Brown NitrofurantoinNitrofurantoin SennaSenna

Reddish brownReddish brown L-dopaL-dopa -methyl dopa-methyl dopa metronidazolemetronidazole

RedRed Red cellsRed cells BeetBeet Phenolphthalein in Phenolphthalein in

laxativeslaxatives Phenothiazine Phenothiazine

(prochlorperazine)(prochlorperazine) DoxorubicinDoxorubicin Vegetable dyesVegetable dyes Concentrated uratesConcentrated urates MyoglobinuriaMyoglobinuria HemoglobinuriaHemoglobinuria

Non-visible haematuria: false positive & Non-visible haematuria: false positive & negativesnegatives

Non-Visible HaematuriaNon-Visible Haematuria Dipstick HaematuriaDipstick Haematuria

+, ++, +++ significant+, ++, +++ significant 91% sensitivity 91% sensitivity

false -: high vit C intake)false -: high vit C intake) 70% specificity 70% specificity

false + heavy bacteriuria, false + heavy bacteriuria, semen, pH>9 eg with oxidising semen, pH>9 eg with oxidising agents to clean perineum, dilute agents to clean perineum, dilute urine (SG < 1.00009)urine (SG < 1.00009)

No distinction between non-No distinction between non-haemolysed or haemolysedhaemolysed or haemolysed

Microscopic haematuriaMicroscopic haematuria 3 RBC/high-power field3 RBC/high-power field

Observer errorObserver error Storage reduces sensitivityStorage reduces sensitivity

Not necessary in primary careNot necessary in primary care

Criteria for significant haematuria criteriaCriteria for significant haematuria criteria

Visible (Macroscopic) Non-visible(3 urine dipstick over 2 to 3 weeks)

Symptomatic “s-VH”Significant if ≥1 episodes contain blood

“s-NVH”Significant if ≥1 of 3 samples dipstick +ve

Asymptomatic “a-VH”Significant if ≥1 episodes contain blood

“a-NVH”Significant if ≥ 2 of 3 urine samples dipstick +ve

Visible Haematuria: Referral CriteriaVisible Haematuria: Referral Criteria

Frank painless haematuriaFrank painless haematuria All need referral under 2 week rule (any age)All need referral under 2 week rule (any age)

Painful haematuria & UTIPainful haematuria & UTI Refer all men with even 1 episodeRefer all men with even 1 episode If persistent, refer If persistent, refer urgentlyurgently haematuria clinic haematuria clinic If 3 UTI in 12 months, If 3 UTI in 12 months, urgenturgent referral to haematuria referral to haematuria

clinic even if clears on antibioticsclinic even if clears on antibiotics If single episode with probable UTI, treat & re-If single episode with probable UTI, treat & re-

evaluate for NVH on 3 further occasions in women. evaluate for NVH on 3 further occasions in women. Follow NVH pathwayFollow NVH pathway

Patients on warfarin should also be referredPatients on warfarin should also be referred

Non-Visible Haematuria (NVH) Non-Visible Haematuria (NVH) initial investigationsinitial investigations

Exclude transient causesExclude transient causes Exercise, UTI, menstrual blood, myoglobinuriaExercise, UTI, menstrual blood, myoglobinuria

UTIUTI Treat & retestTreat & retest Women with repeated UTI need referral (5% of bladder cancers Women with repeated UTI need referral (5% of bladder cancers

present as UTI)present as UTI) All men with haematuria and UTI need referral (even 1, any age)All men with haematuria and UTI need referral (even 1, any age)

≥ ≥ 2 of 3 dipstick positive – Refer to renal physicians if any 2 of 3 dipstick positive – Refer to renal physicians if any below eGFR ↓ or protein ↑ in urinebelow eGFR ↓ or protein ↑ in urine eGFR (< 60 ml/min abnormal)eGFR (< 60 ml/min abnormal) Urinary protein:creatinine ratio ≥ 50 mg/mmolUrinary protein:creatinine ratio ≥ 50 mg/mmol Urinary albumin:creatinine ratio ≥ 30 mg/mmolUrinary albumin:creatinine ratio ≥ 30 mg/mmol

Check blood pressure especially in young patientsCheck blood pressure especially in young patients

a-NVH referral criteria to haematuria clinica-NVH referral criteria to haematuria clinic

<40 years 40-50 years >50 years

Asymptomatic NVH (a-NVH)

risk factors for significant disease refer to haematuria clinic, otherwise monitor

Routine referral to haematuria clinic

Urgent Referral under 2 week wait

Symptomatic (s-NVH)

Routine referral to haematuria clinic

Routine referral to haematuria clinic

Urgent Referral under 2 week wait

Risk factors for significant disease Risk factors for significant disease

SmokingSmoking History of pelvic irradiationHistory of pelvic irradiation Occupational exposure Occupational exposure

dyes, benzenes, aromatic amines, leather, dyes, tires, rubberdyes, benzenes, aromatic amines, leather, dyes, tires, rubber autoworker, painter, truck driver, drill press operator, leather worker, metal worker, autoworker, painter, truck driver, drill press operator, leather worker, metal worker,

and machiners, and machiners, occupations that involve organic chemicals: dry cleaner, paper manufacturer, rope occupations that involve organic chemicals: dry cleaner, paper manufacturer, rope

and twine maker, dental technician, barber or beautician, physician, worker in and twine maker, dental technician, barber or beautician, physician, worker in apparel manufacturing, and plumberapparel manufacturing, and plumber

CyclophosphamideCyclophosphamide

History of urologic disorder or diseaseHistory of urologic disorder or disease Urgency/bladder pain/frequencyUrgency/bladder pain/frequency History of urinary tract infectionHistory of urinary tract infection Analgesic abuseAnalgesic abuse Laxatives causing renal diseaseLaxatives causing renal disease Aristolochic acid use (herbal weight loss remedies)Aristolochic acid use (herbal weight loss remedies) Gonorrhoea (bladder cancer)Gonorrhoea (bladder cancer)

Nephrology ReferralNephrology Referral

↑ ↑ Urinary Protein:creatinine > 50 mg/mmol or Urinary Protein:creatinine > 50 mg/mmol or albumin:creatinine ration > 30 mg/mlalbumin:creatinine ration > 30 mg/ml

Declining GFR by ≥ 10 ml/min within last 5 Declining GFR by ≥ 10 ml/min within last 5 years or by > 5 ml/min in last yearyears or by > 5 ml/min in last year

eGFR < 30 ml/min CKD4eGFR < 30 ml/min CKD4 Isolated haematuria with hypertension if age Isolated haematuria with hypertension if age

< 40 years< 40 years Visible haematuria with intercurrent infection Visible haematuria with intercurrent infection

(usually URTI)(usually URTI)

Long term monitoring of haematuria Long term monitoring of haematuria of unknown aetiology in primary careof unknown aetiology in primary care IndicationsIndications

Not meeting criteria for immediate referralNot meeting criteria for immediate referral Negative urological or nephrological investigationsNegative urological or nephrological investigations

Monitor (annually at least) forMonitor (annually at least) for Development of s-NVH in a patient with a-NVHDevelopment of s-NVH in a patient with a-NVH Lower urinary tract symptomsLower urinary tract symptoms Visible haematuria (development of persistent)Visible haematuria (development of persistent) Proteinuria (worsening or development)Proteinuria (worsening or development) Falling eGFRFalling eGFR High blood pressureHigh blood pressure

6 -12 monthly

AlgorithmAlgorithm

Voided Markers of TCCVoided Markers of TCC

Nuclear Matrix Protein 22Nuclear Matrix Protein 22Much more sensitive (73%) than cytology Much more sensitive (73%) than cytology

(33%)(33%)Cannot replace imagingCannot replace imaging

Less specific (80%) than cytology (99%)Less specific (80%) than cytology (99%)

ImagingImaging IVUIVU

False negative False negative renal masses renal masses 3 cm and 3 cm and anterior/posterior massesanterior/posterior masses

Cannot distinguish solid from cysticCannot distinguish solid from cystic UltrasoundUltrasound

Misses renal masses Misses renal masses 3 cm 3 cm CT CT

Spiral CTSpiral CT Much more sensitive for calculi (98% cf IVU 55%, USS 20%)Much more sensitive for calculi (98% cf IVU 55%, USS 20%)

CT urographyCT urography Preferable & Cheaper than combination of IVU and Preferable & Cheaper than combination of IVU and

CT?CT?

CT Most AccurateCT Most Accurate

CystoscopyCystoscopy

IndicationsIndications Age Age 40 40 All with risk factors for bladder All with risk factors for bladder

cancer including those with cancer including those with benign cause found in upper benign cause found in upper tracttract

Substitute with Substitute with cytology/NMP22?cytology/NMP22? Age Age < 40 years & no risk < 40 years & no risk

factors for malignancy factors for malignancy

Flexible or rigid cystoscopyFlexible or rigid cystoscopy

Interstitial Cystitis Stones

BPHCancer

AlgorithmAlgorithm