Approach to haematuria & dysuria Flashcards
1
Q
What is haematuria?
A
- blood in the urine
- red urine
2
Q
What is haemoglobinuria?
A
- haemoglobin in the urine
- red urine
3
Q
What is myoglobinuria?
A
- myoglobin in the urine
- brown/orange urine
4
Q
What is bilirubinura?
A
- bilirubin in the urine
- yellow/orange urine
5
Q
What is dysuria?
A
- difficulty/pain urinating
6
Q
What is incontinence?
A
- inability to control urination
7
Q
What is stranguria?
A
- straining to urinate
- usually small volumes being produced
8
Q
What is pollakiuruia?
A
- frequent, abnormal urination
9
Q
What is oliguria?
A
- minimal urine production
10
Q
What is anuria?
A
- no urine production
11
Q
What dz in males can manifest as urinary dz but isn’t?
A
- prostate issues
12
Q
What dz in females can manifest as urinary dz but isn’t?
A
- uterine dz
13
Q
Why are females more prone to UTIs than males?
A
- due to a shorter, wider urethra (some bacteria from skin, faecal contamination, etc can make it’s way up the urinary tract)
14
Q
What does gross urinalysis tell us?-
A
- colour (blood/myoglobin/concentration)
- smell
– glucose = sweet
– bacteria = strong smell
– ketones = DKA?
– metallic = bleeding - turbidity (increase in solutes, casts, cells, mucus)
15
Q
How can urine dipstick help differentiate between haematuria and haemoglobinuria?
A
- dots = supportive of blood
- homogenous change = supportive of haemoglobin/myoglobin
16
Q
How can a sediment exam differentiate between haematuria and haemoglobinuria?
A
- 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
17
Q
Haemaglobinuria vs myoglobinuria
A
Blood sample & centrifuge
- plasma likely to be red with haemoglobinuria
- plasma likely to be clear with myogloinaemia
– test for AST & CK
18
Q
Causes of haemoglobinurea
A
- haemoglobinaemia, caused by haemolysis
19
Q
Causes of myoglobinuria
A
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
20
Q
Haematuria - where could the blood have come from?
A
- 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
21
Q
Haematuria - why might something be bleeding?
A
- damage to blood vessels or abnormal blood vessels
– trauma
– urolithiasis
– UTI
– inflammation
– neoplasia - abnormal haemostasis
– coagulopathy - idiopathic
– idiopathic renal haematuria
22
Q
Diagnosing trauma causing haematuria
A
- History and exam
23
Q
Diagnosing urolithiasis causing haematuria
A
- Urine sediment exam,
ultrasound, radiography (contrast)
24
Q
Diagnosing UTI causing haematuria
A
- Urine sample – cytology and C+S
- Ultrasound
25
Diagnosing inflammation causing haematuria
* History, urinalysis, imaging to rule out other causes
26
Diagnosing neoplasia causing haematuria
- CBC – chronic anaemia (due to chronic bleeding)
- Ultrasound and radiography
- endoscopy and biopsy
27
Diagnosing coagulopathy causing haematuria
- CBC; platelet count and PT, aPTT, TEG
28
Diagnosing idiopathic causes of haematuria
- rule out everything else
- CBC for anaemia
- ureteroscopy
29
Idiopathic Renal Haematuria - prevalence, signalment
* Uncommon
* Typically large breed, young dogs
* Unilateral in 75% of cases
* Caused by vascular anomalies in some humans
30
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
31
Idiopathic Renal Haematuria - tx
* ACEi (for proteinuria) and ARBs
* Potentially interventional radiography – sclerotherapy
32
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
33
Ddx for dysuria
- anything that stimulates pain or inflammation
- aka similar to haematuria
34
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
35
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.
36
RTA / trauma: haematuria, dysuria or both?
- mainly haematuria
- but can get neurological damage and/or pain that contributes to dysuria
37
UTI: haematuria, dysuria or both?
- both due to the inflammation caused
38
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
39
Warfarin toxicity: haematuria, dysuria or both?
- haematuria as thins blood
- but same as fulminant hepatic failure in terms of increased risk of UTI -> dysuria
40
Urolthelial carcinoma (transitional cell carcinoma): haematuria, dysuria or both?
- both
41
Idiopathic renal haemturia: haematuria, dysuria or both?
- haematuria
- but clots can attract infection so can get both
42
Urethral sphincter mechanism incompetence (USMI): haematuria, dysuria or both?
- dysuria
43
Ectopic ureter: haematuria, dysuria or both?
- dysuria most likely
44
Differentials for dysuria
- Inflammatory
- Infectious
- Obstructive
- Neuromuscular
- FIC (can become obstructive)
- Drugs
- Anatomical
- Iatrogenic
- Idiopathic
45
Inflammatory differentials for dysuria
- Cystitis – polypoid or pyogranulomatous
- Granulomatous urethritis
- Follicular vaginitis*
46
Infectious cause of dysuria
- Bacterial: E.coli*
47
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
48
Neuromuscular differentials for dysuria
(Urge incontinence)
- Upper motor neuron bladder
- Detrusor Atony (overflow incontinence)
- Urethral sphincter mechanism
incontinence*
49
Drug cause of dysuria
- cyclophosphamide
50
Iatrogenic cause of dysuria
- Irritation secondary to procedures
51
Idiopathic cause of dysuria
- Detrusor hyperspasticity (Urge Incontinence)
52
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
52
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
53
Further diagnostics
- Ex lap
- Endoscopy
54
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
55
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
