Approach to haematuria & dysuria Flashcards
What is haematuria?
- blood in the urine
- red urine
What is haemoglobinuria?
- haemoglobin in the urine
- red urine
What is myoglobinuria?
- myoglobin in the urine
- brown/orange urine
What is bilirubinura?
- bilirubin in the urine
- yellow/orange urine
What is dysuria?
- difficulty/pain urinating
What is incontinence?
- inability to control urination
What is stranguria?
- straining to urinate
- usually small volumes being produced
What is pollakiuruia?
- frequent, abnormal urination
What is oliguria?
- minimal urine production
What is anuria?
- no urine production
What dz in males can manifest as urinary dz but isn’t?
- prostate issues
What dz in females can manifest as urinary dz but isn’t?
- uterine dz
Why are females more prone to UTIs than males?
- due to a shorter, wider urethra (some bacteria from skin, faecal contamination, etc can make it’s way up the urinary tract)
What does gross urinalysis tell us?-
- colour (blood/myoglobin/concentration)
- smell
– glucose = sweet
– bacteria = strong smell
– ketones = DKA?
– metallic = bleeding - turbidity (increase in solutes, casts, cells, mucus)
How can urine dipstick help differentiate between haematuria and haemoglobinuria?
- dots = supportive of blood
- homogenous change = supportive of haemoglobin/myoglobin
How can a sediment exam differentiate between haematuria and haemoglobinuria?
- spin the sample down so supernatant is on top and sediment on the bottom
- RBCs will precipitate and settle on the bottom -> presence of them on cytology
- haemoglobin/myoglobin won’t precipitate and no presence of RBCs on cytology
Haemaglobinuria vs myoglobinuria
Blood sample & centrifuge
- plasma likely to be red with haemoglobinuria
- plasma likely to be clear with myogloinaemia
– test for AST & CK
Causes of haemoglobinurea
- haemoglobinaemia, caused by haemolysis
Causes of myoglobinuria
myoglobinaemia caused by:
- Severe muscle damage
– AST/CK, History, exam.
– Physical causes: trauma/burns/strenuous
exercise/prolonged immobility
– Non-physical causes: hypoxic/ischaemic/metabolic disturbances/infectious
Haematuria - where could the blood have come from?
- anywhere in the uro tract (kidney, ureter, bladder, urethra)
- depending on sample technique
– cystocentesis
– repro tract: prostate, penis, uterus, vagina
– external/mucocutaneous e.g. penile sheath, vulva
Haematuria - why might something be bleeding?
- damage to blood vessels or abnormal blood vessels
– trauma
– urolithiasis
– UTI
– inflammation
– neoplasia - abnormal haemostasis
– coagulopathy - idiopathic
– idiopathic renal haematuria
Diagnosing trauma causing haematuria
- History and exam
Diagnosing urolithiasis causing haematuria
- Urine sediment exam,
ultrasound, radiography (contrast)
Diagnosing UTI causing haematuria
- Urine sample – cytology and C+S
- Ultrasound
Diagnosing inflammation causing haematuria
- History, urinalysis, imaging to rule out other causes
Diagnosing neoplasia causing haematuria
- CBC – chronic anaemia (due to chronic bleeding)
- Ultrasound and radiography
- endoscopy and biopsy
Diagnosing coagulopathy causing haematuria
- CBC; platelet count and PT, aPTT, TEG
Diagnosing idiopathic causes of haematuria
- rule out everything else
- CBC for anaemia
- ureteroscopy
Idiopathic Renal Haematuria - prevalence, signalment
- Uncommon
- Typically large breed, young dogs
- Unilateral in 75% of cases
- Caused by vascular anomalies in some humans
Idiopathic Renal Haematuria - CS & diagnostic findings
- 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
Idiopathic Renal Haematuria - tx
- ACEi (for proteinuria) and ARBs
- Potentially interventional radiography – sclerotherapy
Dysuria: What do we see clinically?
- History or a video of the animal urinating is useful, both stranguria or pollakiuria may have pain as a component, but stranguria is prolonged, painful straining and owners may report ‘a drop at a time’ or tenesmus
Ddx for dysuria
- anything that stimulates pain or inflammation
- aka similar to haematuria
How is dysuria different to haematuria?
- Dysuria is due to lower urinary tract disease – whereas discoloured urine can be from anywhere on the urinary (or repro) tract
What is urge incontinence?
- Very similar to pollakiuria – involuntary bladder contractions voiding small amounts of urine regularly (sometimes referred to as an ‘overactive bladder’).
- Involuntary bladder contractions – neuromuscular and anatomical disease should also be considered
- Anatomical dz for urge incontinence - e.g. enlarged prostate pushing on bladder, bladder will keep firing off as being squeezed.
RTA / trauma: haematuria, dysuria or both?
- mainly haematuria
- but can get neurological damage and/or pain that contributes to dysuria
UTI: haematuria, dysuria or both?
- both due to the inflammation caused
Fulminant hepatic failure: haematuria, dysuria or both?
- clotting factors made in the liver so this could cause a coagulopathy which could lead to haematuria
- could get dysuria secondary as blood in the urine can increase chance of getting a UTI, causing dysuria
Warfarin toxicity: haematuria, dysuria or both?
- haematuria as thins blood
- but same as fulminant hepatic failure in terms of increased risk of UTI -> dysuria
Urolthelial carcinoma (transitional cell carcinoma): haematuria, dysuria or both?
- both
Idiopathic renal haemturia: haematuria, dysuria or both?
- haematuria
- but clots can attract infection so can get both
Urethral sphincter mechanism incompetence (USMI): haematuria, dysuria or both?
- dysuria
Ectopic ureter: haematuria, dysuria or both?
- dysuria most likely
Differentials for dysuria
- Inflammatory
- Infectious
- Obstructive
- Neuromuscular
- FIC (can become obstructive)
- Drugs
- Anatomical
- Iatrogenic
- Idiopathic
Inflammatory differentials for dysuria
- Cystitis – polypoid or pyogranulomatous
- Granulomatous urethritis
- Follicular vaginitis*
Infectious cause of dysuria
- Bacterial: E.coli*
Obstructive differentials for dysuria
- Urethral Stricture
- Urolithiasis*
- Urethral plug
- Perineal hernia, post-spay granuloma/ stump pyometra
- Prostatic disease* (Stranguria)
– Prostatitis
– Prostatic abscess - Neoplasia
– TCC, Prostatic adenocarcinoma, urethral leiomyoma
Neuromuscular differentials for dysuria
(Urge incontinence)
- Upper motor neuron bladder
- Detrusor Atony (overflow incontinence)
- Urethral sphincter mechanism
incontinence*
Drug cause of dysuria
- cyclophosphamide
Iatrogenic cause of dysuria
- Irritation secondary to procedures
Idiopathic cause of dysuria
- Detrusor hyperspasticity (Urge Incontinence)
Is the animal blocked or not?
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
Small Bladder: non-obstructive disease
- Anatomical – e.g. ectopic ureters
- Neuromuscular – e.g. USMI
- Inflammatory, infectious, iatrogenic or idiopathic
- FIC
Imaging: should we use CT? Specific use examples
- if required in workup, yes
Specific use examples:
* Investigation/ characterization of a mass
* Assessment of tumour spread or surrounding
tissue involvement, metastasis
* Ectopic ureter
– Diagnosis
– Characterisation
Further diagnostics
- Ex lap
- Endoscopy
Ex lap - uses
- Allows direct visualisation
– Neoplasia - Allows for biopsy/sampling/curative surgery
- Technical expertise for procedures otherwise major complications;
– Bladder mass incisional biopsy –> uroabdomen
– Bladder mass excisional biopsy –> curative
Endoscopy - uses
- Allows for direct visualisation (via a screen)
– Ectopic ureters
– Neoplasia
– Idiopathic renal haematuria (identify the ureter) - Allows for biopsy/sampling
- Reduced risk of trauma – but can perforate a fragile bladder
- Technical expertise – specialist training to use and interpret
