Approach to haematuria and dysuria

Question 1

How can you differentiate haemoglobinuria, haematuria and myoglobinuria?

Answer 1

• Blood sample and centrifuge
  
  • Plasma likely to be red with haemoglobinaemia
  • Plasma likely clear with myoglobinaemia
    
    • Test for muscle markers (AST and CK)
      Both products end up in the urine due to being at high levels in the blood and being filtered by the nephrons.

haematuria
* RBCs on sediment exam
* Clear (ish) plasma and centrifuged urine
* Presence of regenerative anaemia may be supportive of haemorrhage.
* What and why is there bleeding?
◦ damage to vessels
◦ abnormal haemostasis (and of course, idiopathic)
- But if the urine is sitting round then RBCs can haemolyse can can have haematuria with Haemoglobinuria

Question 2

What are causes of haemoglobinaemia and myoglobinaemia?

Answer 2

Haemoglobinaemia
Haemolysis –> See pre-hepatic jaundice and haemolytic disease

Myoglobinaemia
* Severe muscle damage
◦ AST/CK, History, exam.
◦ Physical causes – trauma/burns/strenuous exercise/prolonged immobility
◦ Non-physical causes – hypoxic/ischaemic/metabolic disturbances/infectious
(will be brown tinged)
myoglobinaemia is bad of the kidneys can then develop AKI

Question 3

Where can the blood in haematuria come from?

Answer 3

• Damage to blood vessels
  ◦ Trauma –> History and exam
  ◦ Urolithiasis –> Urine sediment exam, ultrasound, radiography (contrast)
  ◦ Urinary tract infection (incl. Prostatic)
  ◦ Inflammation (e.g. FIC, prostatitis)
  ◦ Neoplasia
• Abnormal haemostasis
  ◦ Coagulopathy
  ◦ Neoplasia (abnormal vessels)
  ◦ Idiopathic - Idiopathic renal haematuria

Question 4

What is idiopathic renal haematuria? What can it lead to? How can it be treated?

Answer 4

• Uncommon
• Typically large breed, young dogs
• Unilateral in 75% of cases
• Caused by vascular anomalies in some humans
• Haematuria; potentially passing clots, or seeing them in the bladder via ultrasound

Can lead to:
* Anaemia; Renal pain; Ureteral pain and/or ureteral obstruction; UTI’s

Treatment
* ACEi (for proteinuria) and ARBs
* Potentially interventional radiography – sclerotherapy

Question 5

What are differentials for dysuria?

Answer 5

• Inflammatory
  ◦ Cystitis – polypoid or pyogranulomatous
  ◦ Granulomatous urethritis
  ◦ Follicular vaginitis
• Infectious
  ◦ Bacterial – E.coli
• Obstructive
  ◦ Urethral Stricture
  ◦ Urolithiasis
  ◦ Urethral plug
  ◦ Perineal hernia, post-spay granuloma/ stump pyometra
  ◦Prostatic disease(Stranguria)
  ◦ Neoplasia
• Neuromuscular (Urge Incontinence)
  ◦ Upper motor neuron bladder
  ◦ Detrusor Atony (overflow incontinence)
• FIC (can become obstructive)
• Drugs – e.g. cyclophosphamide
• Anatomical
  ◦ Ectopic ureters, urethral dysplasia (Urge Incontinence)
• Neuromuscular (Urge Incontinence)
  ◦ Urethral sphincter mechanism incontinence
• Iatrogenic
  ◦ Irritation secondary to procedures
• Idiopathic
  ◦ Detrusor hyperspasticity (Urge Incontinence)

Question 6

What is one of the most important decisions when working up a haematuria and dysuria?

Answer 6

Whether the bladder is blocked
Express the bladder - it should empty

Question 7

What are causes of obstructive disease and small bladder (non obstructive disease)?

Answer 7

Obstructive disease
* Failure of bladder to empty (neuromuscular)
◦ Detrusor atony – overstretch and damage – flaccid, easy to express
◦ UMN bladder (Thoraco-lumbar disease) – urethral sphincter tone remains high preventing urination, difficult to express
* Inflammatory, infectious, iatrogenic can all have a big bladder.

with blocked worried about backing up to the kidney, AKI, reduced excretion of electrolytes , increase in potassium , bradycardia, death

Small Bladder – non-obstructive disease
* Anatomical – e.g. ectopic ureters
* Neuromuscular – e.g. USMI
* Inflammatory, infectious, iatrogenic or idiopathic
* FIC
If this cat is in the hospital, make sure to frequently check it is urinating and palpate bladder, can become blocked due to stress of hospital

Question 8

What kidney issue is this an example of?

Answer 8

Hydronephrosis - pyramids are expanded and pushed apart
* won’t always be present in obstructed patient
* indicates that has been present for a while
* if unilateral, blocked ureter on that side

Question 9

What kidney issue is this an example of?

Answer 9

renal cysts - can be an incidental finding if just one, not the issue
* if multiple can be polycystic kidney disease
* can have lots of small cysts

Question 10

What kidney issue is this an example of?

Answer 10

Nephroliths - stone with distal acoustic shadowing