HAEMATURIA.

By J. SWAIFT JOLY, M.D., F.R.C.S.

(Senior Surrgeon to St. Peter's Hospital for Stone, London.)

Hematuria is the passing of blood in the urine. It is not a disease, but isa symptom of many diseases. There is usually no difficulty in diagnosing thepresence of blood, but there is often great difficulty in determining the site ofthe hamorrhage and also the pathological condition giving rise to it. It isobvious that blood found in the urine may come from one or both kidneys, orfrom any part of the urinary passages, ureters, bladder, urethra, etc., and maybe due to a variety of causes. My object is to facilitate the diagnosis of theposition and nature of the underlying lesion by describing the various formsthat the symptom of haematuria may take.

The microscope gives us the most accurate test of blood in the urine. Thenext best is the appearance of a perfectly fresh specimen viewed by the nakedeye. Both depend on the presence of red blood corpuscles. Urine may becoloured red by hremoglobin although it does not contain any red cells. Thiscondition is called haemoglobinuria, but it is not a true hamaturia. The two con-ditions can usually be distinguished by simple inspection. In the former the urineis absolutely translucent, in the latter it is opaque. If there is only a small amountof blood in the urine, the specimen has a smoky appearance, due to a mixtureof turbidity and colouration. When there is a large amount, the appearance isunmistakable. At the same time, red blood cells may be found in specimens thatappear to be absolutely normal to the naked eye. We speak of this conditionas a "microscopic haematuria " or an " occult hiematuria. " The chemical tests forblood depend on the presence of hemoglobin, and do not distinguish betweena hmoglobinuria and a true hxmaturia. They have been practically abandonedby urologists, but are still of use when the urine contains abnormal colouringmatter.

In order to avoid repetition, it is necessary to do-fine certain terms in commonuse. An " initial hamaturia " indicates that the blood appears entirely orchiefly in the first portion of urine voided, a " terminal hematuria" is used toconnote the presence of blood in the last portion, while a "total haematuria "

indicates that the whole of the urine is uniformly blood stained. These formsmay be distinguished by asking the patient to pass water into two glasses, andby noting which is more deeply stained. In many cases, the patient notices thateither the first or the last few drops of urine he passes are blood stained, whilethe remainder is clear. These are simply examples of initial or terminalhaematuria.

An initial haematuria usually indicates that the hafmorrhage takes place intothe urethra, and the blood is washed out by the first gush of urine. A terminalhaematuria is usually vesical in origin. If the kidneys are bleeding, the urine isuniformly stained, and the hamaturia is total. In this way a rough guess as tothe site of the hemorrhage is obtained, but it should be remembered that in aprofuse hematuria the wvhole of the urine may be uniformly coloured, no matterwhere the bleeding point may be.

June, 1935 H.-:,MAT1 RIA 213copyright.

on June 22, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.11.116.213 on 1 June 1935. D

ownloaded from

POST-GRADUATE MEDICAL JOURNAL

The presence of blood clots is important, and one should look for them byslowly pouring off the urine till only a small quantity remains in the bottom of theglass, and then filling the vessel with water. On agitating the water, the clotswill be seen distinctly. When the heemorrhage takes place into the renal pelvis,long thin worm-like clots are often passed. They are about as thick as whipcord,or an ordinary ureteric catheter, and may be several inches in length. They areformed by the blood coagulating as it passes down the ureter, and therefore indi-cate a brisk haemorrhage into the renal pelvis. I have only seen this form ofclot in cases of ruptured kidney and of renal neoplasm. In the absence of ahistory of injury they are extremely suggestive of a new growth. In many casestheir passage is accompanied by a renal colic, which at once gives an indicationof the affected side. Blood clots originating in the bladder are of no particularshape. If small they are often compared with tea leaves, if they are large theymay give rise to difficulty in micturition. When the bladder becomes filled withclot, retention may ensue. Clots forming in the posterior urethra are usuallywashed out in the first gush of urine. If the hemorrhage is severe they maypass back into the bladder, and even give rise to clot retention. Instrumentallaceration of the posterior urethra is sometimes followed by clot retention.

Renal Hematuria.In this condition bloody urine can be seen on cystoscopy issuing from one

or both ureters. If the bleeding is slight one can only say that the efflux issomewhat turbid, but if it is severe the appearance is unmistakable, and resemblesa puff of smoke from the stack of a locomotive.

Nephritis is undoubtedly the most common cause of a reinal haematuria.Usually the bleeding is slight, and gives the urine a characteristic smoky appear-ance. It is also continuous, and blood may be found in the urine for days orweeks at a time. If the patient is cystoscoped, a slightly hazy efflux is observedon both sides, but this examination is rarely made as other signs of nephritis areusually well marked. They are, a high blood pressure wvith thickened arteriesand a hypertrophied or dilated heart, flame shaped haemorrhages in the retinae,and often cedema. The urine contains more albumin than one would expect fromthe amount of blood, tube casts are also present, and the response to the renalefficiency tests is bad. Occasionally intermittent attacks of severe hamorrhageare noticed. They were comparatively common in cases of " trench nephritis"during the war. In every case I saw, the bleeding was unilateral, and invariablycame from the worse of the two kidneys. Blood clots are never found in casesof nephritis, their place being taken by blood casts. Personally, I believe thatthe presence of large blood clots in the urine indicates that the haemorrhage takesplace directly into some part of the urinary passages, and not into the kidneyitself.

A most important type of hematuria is what the French surgeons call the"neoplastic type." The bleeding commences suddenly, is profuse and unaccom-panied by pain, except when clots are passed, and ceases as suddenly as itcommenced. An attack may last for a few hours, blood being only present inthe urine passed in one or two acts of micturition, or it may persist for severaldays. The intervals between consecutive attacks may be several weeks or months,but as a general rule they become shorter as the disease advances. This type ofhaematuria is characteristic of a growth in the kidney, ureter, or bladder, and is

214 June, 1935copyright.

on June 22, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.11.116.213 on 1 June 1935. D

ownloaded from

an urgent indication for a complete urological examination. If the patient is seenduring an attack of bleeding he should be cystoscoped at once. There is no diffi-cultv in obtaining a clear view if a modern irrigating cystoscope is used. Specialnote should be made of the efflux from both ureters. If bloody urine is seenissuing from one, a pyelogram will most probably reveal the position and to acertain extent the size of the renal tumour. Even when a vesical neoplasm ispresent, one should still examine the effluxes, as the bladder growth may besecondary to one in the renal pelvis. When the patient is seen in a blood-freeperiod, an intravenous pyelogram gives the quickest means of locating the growth.In any case, I think it advisable to have a cystoscopic pyelogram before advisingoperation for a suspected renal neoplasm. By the intravenous method one obtainsinformation as to the physiology of the kidney, while the cystoscopic pyelogramshows up any anatomical change in the renal pelvis. If a renal neoplasm givesrise to hamorrhage it has in practically every case broken into the renal pelvis orinto a calyx. It then gives rise to some change in the pyelogram, usually in thenature of a filling defect. Occasionally the change is so slight that it may bemissed unless a careful and methodical examination of all the calyces is made.In such cases it is often useful to have pyelograms of both sides, as the formationof the pelvis and calyces is usually similar for both kidneys. Tumours of therenal pelvis and ureter also give rise to filling defects, but as these growths areusually papillary the outline of the defect may showv characteristic saw-like edges.

Polycystic disease of the kidneys is occasionally associated with haematuria,which may be unilateral. The combination of an enlarged nodular kidney withrenal hemorrhage may lead to a suspicion of a new growth. The true diagnosiscan be made by pyelography, which shows (i) that there is no filling defect, and(2) that the calyces are greatly elongated, so that the whole pyelographic picturecovers a much greater area than usual, and (3) that the condition is bilateral.In addition, the response to the renal function tests is uniformly bad. This isnot the case when a neoplasm is present.

The type of hoematuria met with in cases of renal calculus is quite differentfrom that just described. In dealing with this symptom, one must distinguishbetween infected and uninfected lithiasis. When the urine is sterile, blood canbe found in practically every specimen, but in about two-thirds of the cases it canonly be detected by means of the microscope. In the remaining third, it is sufficientlycopious to be noticed by the patient himself. The amount of blood in the urineis definitely increased by exercise or jolting, and is diminished by rest. In a fe'winstances, the patient has volunteered the information that he only bleeds in theevening, that is after his day's work. In such cases, however, a few red bloodcells can always be discovered in the morning urine. Before the introduction ofradiography, this effect of exercise was employed by the French surgeons as adiagnostic test. The patient was first confined to bed for 24 hours, and thenumber of red blood cells in each field of the microscope was noted. He was thenordered to get up and walk about. If the number of blood cells was increased,the diagnosis of stone was confirmed. At present radiography has rendered testsof this nature unnecessary. When the kidney is infected, it is usually said thatthe bleeding is diminished. It might, perhaps, be more correct to say that it ismore difficult to find red blood cells in the urinary sediment, as they are hidden

June, 1 935 HA,NlA'I.1U R I A\ 215copyright.

on June 22, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.11.116.213 on 1 June 1935. D

ownloaded from

by great masses of pus cells. Macroscopic haematuria is, however, about ascommon in infected as in uninfected cases, but the microscopic discovery of redblood cells is distinctly less so. In both forms of lithiasis, any condition whichgives rise to pain is also prone to increase the amount of haematuria. For thisreason, blood is present in practically every case of renal colic, while it is onlyfound in about IO per cent. of the acute crises of hydronephrosis.

As a rule haematuria is less common in cases of ureteric than of renal calculi.In about I2 per cent. of cases no blood cells are found on microscopic examina-tion. Occasionally the haematuria is severe, and the urine may be almost blackfrom blood. This, however, is rare, and a copious haemorrhage should raisesuspicion of a new growth in addition to the stone.

A severe attack of haematuria may be the first symptom of either renal tuber-culosis or of a Bacillus coli pyelitis. As a rule the bleeding is not repeated, but itmay be of sufficient intensity to alarm the patient. A bacteriological examinationof the urine, made after the bleeding has ceased, is usually sufficient to permit of thecorrect diagnosis. When tuberculosis is started by an attack of hamaturia,nephrectomy should not be delayed, as the disease usually runs a rapid course.

Occasionally purpura of the renal pelvis gives rise to severe bleeding. Suchcases are very puzzling, as the result of the urological examination is com-pletely negative, except that bloody urine is coming down from one kidney. Ifpurpuric spots are found on the skin, or if the patient gives a history of previousattacks of purpura, one should suspect it as being the cause of the haemorrhage.In many cases a subcutaneous injection of I or 2 cCs. of antistreptococcic serumcompletely stops the bleeding, but in some it has no effect. If it fails, a bloodtransfusion may be of use, but occasionally conservative treatment is unsuccessful,and one may have to remove the kidney. In one case I had to remove the kidneyfor severe haemorrhage which lasted for six wveeks, and I have seen a few similarcases. The only lesions found in the excised kidnevs were a fewv submucoushamorrhages in the renal pelvis.

A subcutaneous injury of the kidney alvays gives rise to haematuria, unlessthe ureter is completely severed. As a rule, the bleeding lasts for about a weekand then gradually dies away. It may, however, be interrupted by the passageof clots down the ureter, in which case there is a renal colic, and the urine isclear as long as the pain lasts. Rupture of the kidney is always associated witha perinephritic haematoma. Its size should be determined by ordinarv physicalexamination within the first 24 hours. Any subsequent increase in size denotescontinued bleeding, and may indicate operation. It is most important to lookfor signs of intra-peritoneal haemorrhage, or injury. If the abdomen is becomingdistended, or tender, while the pulse rate is increasing, it is far safer to make anexploratory incision. There may be an injury to the liver or spleen, whichrequires immediate treatment, or if the peritoneum over the kidney is torn, andthe patient is bleeding into his peritoneal cavity, the kidney should be removed.If there are no complications the patient should be watched. In most casesthe haematoma becomes absorbed, and the patient makes a satisfactory recovery.Very little permanent damage to the kidney appears to result from the injury,

216 POST-GRADUATE MEDICAL JOURNAL June, 1935

copyright. on June 22, 2020 by guest. P

rotected byhttp://pm

j.bmj.com

/P

ostgrad Med J: first published as 10.1136/pgm

j.11.116.213 on 1 June 1935. Dow

nloaded from

but the patient should be kept under observation for several months, as occa-sionally a chronic nephritis supervenes.

Secondary hemorrhage following nephrotomy is not uncommon. Statisticsvary greatly on this point, the lowest figure being that of Braasch and Foulds(5.3 per cent.), and the highest was recorded by Cifuentes (I3.6 per cent.). Itis a serious complication as it usually involves a loss of the kidney. It is, in myexperience, most common in cases where the organ had a good excretory functionbefore the operation. The convalescence is usually normal for the first week orso, except for a somewhat irregular temperature which is rarely high enough togive rise to anxiety. Then the bleeding suddenly commences. If the kidney hasbeen drained, blood may come through the sinus, but it is much more commonfor it to take the form of a profuse haematuria, which may either be continuous ormay have intermissions lasting for a fewv days. If it shows no sign of clearingup spontaneously, the kidney must be removed. One should not wait till thepatient is bled white before operating, as this only increases the risk. As soonas general signs of loss of blood occur, the patient should be transfused and thekidney removed without delay. In most cases an examination of the specimenfails to reveal any definite bleeding point.

Vesical Hamaturia.A bladder tumour gives rise to attacks of profuse haematuria, with long

periods between them in which the urine is perfectly clear to the naked eye. Itmay, however, contain a few red blood cells.

It is most important to realise that an intermittent haematuria is the earliestsymptom of both benign and malignant tumours of the bladder, and that the twotypes cannot be distinguished clinically at this period. The usual text-bookdescription of the symptoms of malignant disease of the bladder refer only to thelate stages, when the growth is inoperable. A vesical carcinoma is, in my experi-ence, always inoperable when a mass can be felt on bimanual examination in themale, and generally inoperable when it can be felt in the female. The symptomsof pain and frequency of micturition occur late, and are usually due to infection,though occasionally they appear when the urine is still sterile. They then indicatethat the muscular tissue of the bladder wall is extensively involved, and thereforethat operative treatment has little chance of success. In order to obtain the bestresults in cases of malignant disease of the bladder, one must operate before thecharacteristic symptoms arise, that is before the condition can be diagnosedclinically. A sudden attack of haematuria is always a definite indication for animmediate cystoscopy, as it is usually caused by a neoplasm either of the bladderor the kidney.

If the patient is only seen in the late stages, one obtains a history of repeatedattacks of symptomless hematuria, with gradually decreasing intervals betweenthem. Sooner or later frequency of micturition with pain during the act super-vene. If the growth is non-infiltrating, these symptoms are the result of an instru-mental cystitis, if it is invasive, they arise spontaneously. This is the first clinicaldifferentiation between benign and malignant growths of the bladder. The latesymptoms of a vesical carcinoma are: great frequency of micturition, amounting

June, 1 935 H:EMA,rURIA.- 217copyright.

on June 22, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.11.116.213 on 1 June 1935. D

ownloaded from

to every hour or half-hour by day and night; pain before, during, and after theact; the passage of foul blood-stained urine, containing much pus and necroticshreds from the growth. The patient soon becomes worn out by pain and lossof sleep, and one cannot do much to relieve him. Drugs are of little use. Acystotomy usually makes the patient worse. On the whole, I think that a pre-sacral neurectomy holds out the greatest hope of relief.

Clot retention is a fairly common complication of bladder tumours. It alsooccurs after instrumentation, especially when the urethra is "difficult," or theinstrument large and awkwardly shaped. It is therefore most common afterurethral dilatation, and after litholapaxy. Clot retention may result from asecondary haemorrhage after prostatectomy, or some operation on the bladder.It may also be due to severe renal hemorrhage. In all cases the bleeding is sorapid that large clots form in the bladder, and effectively prevent the passage ofurine. The bladder may be completely filled with clot, or there may be a thicklayer of coagulum on the base, with blood-stained urine above it. In either casethe bladder rapidly becomes over-distended, and its unavailing efforts to expel theclots give rise to great pain. The passage of an ordinary catheter gives no relief,as its lumen immediately becomes blocked. The cannula of a Bigelow's evacuatorshould be passed, and the clots evacuated, just as one evacuates the fragmentsof a calculus in litholapaxy. If an evacuating cannula is not available, a full-sized metal catheter with a large eye should be passed. If it becomes blocked, asmall amount (about half an ounce) of water should be forcibly injected intothe bladder. This will free the catheter and enable some more clot to pass throughit. This method is definitely inferior to evacuation, but should be tried as anemergency. If these per-urethral methods fail, the bladder must be opened andthe clots turned out. When the bladder is emptied it should always be drained.An in-dwelling catheter is sufficient when the clot is evacuated, but a supra-pubictube should be used after a cystotomy. If the bladder is kept empty the bleedingusually ceases, except in the rare cases where it originates in the kidney.

Clot retention is a serious complication of vesical growths. The clot becomesimpregnated with tumour cells and may give rise to implantation growths in otherparts of the bladder, or in the posterior urethra. If the bladder is opened, sec-ondary deposits are very prone to occur in the abdominal wall. The wound shouldbe carefully packed off before incising the bladder wall.

The haematuria associated with vesical calctulus is of an entirely differenttype. In such cases a few drops of blood are passed at the end of each act ofmicturition. The bladder contracts on tlle stone, which lacerates the delicatemucous membrane and gives rise to a slight amount of bleeding. It is interestingto note that this terminal heematuria is only present when the bladder can beeinptied completely. It occurs in children, and in adults up to middle age, butnot when stone is a complication of an enlarged prostate. Even a comparativelysmall amount of residual urine is sufficient to shield the bladder from injury, andto prevent the terminal hoematuria. A prostatic patient with a calculus usuallypasses blood in his urine after exercise or jolting, and this is the only form ofhnzimaturia caused by his stone. Exercise also increases the amount of bleedingin cases of uncomplicated stone, and as the blood becomes intimately mixed with

218 POST-GRADUATE MEDICAL JOURNAL June, 1935copyright.

on June 22, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.11.116.213 on 1 June 1935. D

ownloaded from

the urine the hematuria is total. Many stone patients voluntarily terminate theact of micturition before the bladder is completely emptied, in order to avoid thepainful spasm that occurs at the end of the act. This also does away with theterminal haematuria, but the presence of a calculus may be surmised from thehistory, and from the fact that a few red blood cells are still present in the urinarydeposit.

A terminal hxmaturia is often caused by inflammatory conditions of thebladder. It is frequently observed in cases of acute cystitis, especially when theregion of the internal meatus is involved. It is also present in cases of tuberculousulceration of the bladder. In countries, such as Egypt and South Africa, wherebilharziosis is common, a history of terminal haematuria at once leads to anexamination of the urinary deposit for ova. It is there by far the most commoncause of haematuria. In all these cases the bleeding is due to spasm of themuscular wall of the bladder, which squeezes a small amount of blood from theinflamed or ulcerated mucosa.

Occasionally severe haemorrhage arises from rupture of a varicose vein on thebase of the bladder. These veins are not uncommon, and unless the blood isactually seen coming from one, caution should be exercised in making a diagnosis.If the bleeding has ceased when the examination is made, one should not assumethat they are the cause until the kidneys have been proved to be healthy. Whena bleeding vein is actually seen, the haemorrhage can be stopped by touching thebleeding point with a fulguration electrode.

Prostatic and Urethral HFmorrhage.Haemorrhage from the prostate is usually the result of instrumentation, though in

a few cases it is apparently spontaneous. This applies especially to cases where thegland is enlarged. In the adenomatous type one very frequently finds that thepassage of a catheter is followed by a few drops of blood, which either appear in thelast portion of urine drawn off, or at the external meatus on withdrawing the instru-ment. I am always rather pleased to see a drop or two of blood on catheterization,as it is a strong indication that the gland is innocent. A malignant prostate doesnot often bleed in this manner. In fact, hfemorrhage is a rare symptom of prostaticcarcinoma, especially in its early stages. An advanced growth may give rise tohaematuria, but the blood then comes from secondary deposits in the bladder, and thehamaturia resembles that of a vesical neoplasm. Severe haematuria following instru-mentation in a case of prostatic enlargement is an indication that a serious injuryhas been inflicted on the prostatic urethra. The blood passes back into the bladderand clots there. Clot retention is very likely to follow. These cases are difficultto treat, as the urethra is always " difficult," and is rendered still more so by thepresence of the false passage. It is safer to open the bladder and turn out theclots. If the haemorrhage has not ceased, and blood is seen coming from theposterior urethra, or from a laceration of the intravesical projection, a prostatec-tomy should be performed. A moderate degree of instrumental haemorrhage may,however, be treated by tying in a catheter.

Spontaneous haemorrhage is frequently described in cases of prostatic enlarge-ment. It is, however, dangerous to assume, as is frequently done, that hematuriaoccurring in a prostatic patient is always due to the state of the gland. It may becaused by a stone, or by a growth in the bladder or in the kidney. I have seen

June, 1 935 HAi:EMATU RI A 219copyright.

on June 22, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.11.116.213 on 1 June 1935. D

ownloaded from

four cases of renal neoplasm, where prostatectomy was advised, and two where itwas actually performed, because the gland was somewhat enlarged and the patienthad intermittent attacks of haematuria. Such mistakes would not occur if thesurgeon took the precaution of insisting on an intravenous pyelogram wheneverthe source of the bleeding was not obvious. Blood is often seen passing back-wards from the posterior urethra when a prostatic patient is cystoscoped, butthis is instrumental and quite unconnected with any spontaneous hoematuria thepatient may have noticed. Enlarged and engorged veins are often seen on theintravesical projection of the prostate, and are frequently pointed out as possiblesources of haemorrhage. They may bleed, but I maintain that they should notbe assumed to be the cause of the hamaturia until every other possible sourcehas been excluded. I also maintain that a spontaneous hematuria is not acommon symptom of benign enlargement of the prostate, although many textbooks of surgery state that it is.

Haemorrhage from the posterior urethra in cases where the prostate is notenlarged may also be instrumental or spontaneous. The former is rarely severeand seldom requires special treatment. Occasionally it may be necessary to tiein a catheter for a few days, but it is extremely rare that a cystotomv is necessary.False passages are quite common in the posterior urethra, after dilatation of astricture in the anterior portion. The shaft of the instrument is gripped by thestricture and the surgeon has little control over its point and may have difficultyin determining wvhere it lies. A false passage just belowN, the internal meatusadds greatly to the difficulty in treating strictures.

A spontaneous hamorrhage from the posterior urethra mav be caused by anew growth, but is more often due to inflammatory conditions. Urethral growthsare, as a rule, secondary implants from a vesical or even a renal papilloma. Theblood usually collects in the urethra between the acts of micturition, and isexpelled with the first jet of urine. It is therefore initial. In cases of severeurethritis, prostatitis, etc., a few drops of blood may be squeezed from the inflamedmucous membrane when the sphincters contract at the end of the act. In suchcases the hematuria may be terminal. The treatment is simply the treatment ofthe underlying cause.

Haemorrhage from the anterior urethra is usually accompanied by a continuousflow from the external meatus between the acts of micturition. This is not a truehaematuria. If, however, the bleeding is slight, the blood may collect in the bulband only appear in the first portion of urine passed. This is another example ofan initial hxmaturia.

:o :

220 POST-GRADUATE TMEDICAL JOURNAL juiie, 1935copyright.

on June 22, 2020 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.11.116.213 on 1 June 1935. D

ownloaded from