1: Haematuria

Question 1

define haematuria

Answer 1

presence of blood in the urine either visible or non-visible

Question 2

how can haematuria be classified

Answer 2

• visible (VH): blood is visible in the urine making it pink, red or dark brown
• non-visible (NVH): blood is present in the urine on urinanalysis but not visible

Question 3

how can NVH be further classified

Answer 3

• symptomatic (s-NVH): presents with associated symptoms e.g. suprapubic pain or renal colic
• asymptomatic (a-NVH): no associated symptoms

Question 4

what are common urological causes of haemturia

Answer 4

• UTI
• renal, bladder, prostate cancer
• renal calculi
• BPH

Question 5

what are medical causes of haematuria

Answer 5

• GN e.g. IgA nephropathy
• thin basement membrane disease
• haemolytic uraemic syndrome

Question 6

what is pseudohaematuria

Answer 6

red or brown urine that is not secondary to the presence of Hb
e.g. rifampicin or methyldopa, hyperbilirubinuria, myoglobinuria and foods e.g. beetroot or rhubarb

Question 7

what questions are important when taking a history in haematuria

Answer 7

• degree of haematuria
• presence of clots
• timing in stream
• associated symptoms: LUTS, fevers, suprapubic or flank pain, weight loss, recent trauma
• drug history + smoking status
• industrial carcinogen exposure or recent foreign travel (schistosomiasis)

Question 8

what examinations would you carry out in haematuria

Answer 8

abdo exam + DRE/external genitalia

Question 9

why is it important to inquire about timing in stream in haematuria

Answer 9

• total haematuria suggests bladder or upper tract source
• terminal haematuria suggest potential severe bladder irritation

Question 10

what are important investigations into haematuria

Answer 10

• urinalysis: nitrites and/or leukocytes show infection?
• bloods: FBC, U&Es, clotting, PSA where prostatic pathology might be indicated
• urinary protein levels e.g. spot albumin:Cr or protein:Cr in those with deranged renal function/suspected nephrological cause

Question 11

what is involved in the urological referral criteria for haematuria

Answer 11

• aged >45 yrs with either: unexplained VH - UTI or VH that persists after successful treatment of UTI
• aged >60 yrs with unexplained NVH + either dysuria or raised WCC on a blood test

Question 12

what is the gold standard investigation for assessing the LUT

Answer 12

flexible cystoscopy
- should be performed in all cases of haematuria where feasible
- often performed under local

Question 13

what other imaging might be relevant in cases of haematuria

Answer 13

upper urinary tract imaging
- US of renal tract for NVH
- CT urogram for VH

Question 14

what is the management of haemturia

Answer 14

treatment of underlying pathology
- review anticoags, clotting disorders, blood transfusions
- those with clot retention will need 3 way catheter insertion for ongoing washout and irrigation +/- evacuation of clots

Question 15

what are the main components of a urine dipstick and state their significance

Answer 15

• glucose: should be absent; glycosuria causes include DM, renal tubular diease, some meds e.g. SGLT2 inhibitors
• bilirubin: ↑= inc conjugated bilirubin due to biliary obstruction e.g. pancreatic cancer
• ketones: DKA
• pH: ↓ starvation, DKA, sepsis ↑ UTI, vomiting, diuretics
• blood: RBCs, Hb, myoglobin = UTI, renal stones, rhabdo, nephritic syndrome, malignancy
• protein: proteinuria = nephrotic syndrome and CKD
• nitrites: UTI
• leukocyte esterase (enzyme produced by neutrophils): +ve indicates WCC in urine so infection

Question 16

which patients presenting w haematuria need to be referred

Answer 16

• eGFR <60
• significant proteinuria
• abnormal BP