Case 14 - Haematuria Flashcards
What is haematuria?
Presence of blood in the urine
Macroscopic/frank is when the blood is visible to the patient
Microscopic when there’s >5 RBC/mm3
Should do dipstick first before microscopy
Beetroot, rifampicin, myoglobin etc. can all make the urine look red
What could cause haematuria?
Trauma Urological stones UTI Bladder cancer Renal tumour Prostate disease Glomerular disease Enlarged kidneys
Haematuria history
Duration How many times it has happened Any similar episodes Volume of blood Clots? Pain on urination/elsewhere? Fever Weight loss Smoking Occupational exposure to dyes Medications the patient is on FHx PMHx e.g. HTN
What investigations are needed in haematuria?
Urine analysis
BTs - FBC, CRP, U and E
Imaging - USS KUB initially
For female without UTI and males
What urine analysis should be done?
Urine dip - to test for protein and blood
If both positive, likely to be glomerular haematuria - dysmorphic RBC will be seen on microscopy
Can then culture and sensitivity if there’s an infection
What blood tests should be done?
U and Es to check kidney function FBC - WCC for infection, Hb for anaemia CRP Blood cultures for an infection PSA
What imaging should be done?
Flexible cystoscopy for everyone
USS KUB or CT urogram if obstruction is suspected
What is the 2WW criteria for haematuria?
Testicular lump
Penile lump and no apparent infection
Over 60, with unexplained microscopic haematuria
Increased PSA
Over 45 with non-resolving UTI, or unexplained macroscopic haematuria
What is glomerular haematuria?
Find blood and protein in the urine due to glomerular dusyfunction/damage
Symptoms may include a preceding URTI (IgA nephropathy), rash (vasculitis), systemic symptoms
May have known HTN
All investigation often normal apart from low GFR and haematuria
Confirm with biopsy
What are the types of kidney tumours that can cause haematuria?
Can be benign - angiomyolipoma
Renal cell carcinoma - haematuria, pain, mass
Resection/immunotherapy
Transitional cell carcinoma - haematuria, pain LUTS
Resect or intravesicular chemo
Papillary necrosis - Necrosis and shedding of medullary papillae due to infarction, this can cause obstruction
Needs urgent drainage and Abx
What are the causes of urological stones
Metabolic dysfunction ie. Crohns
Urological abnormality
Recurrent infections
Immobilisation
How do you image urological stones?
Depends on the type of stone:
Calcium oxalate seen on X ray
Struvite - staghorn appearance on X ray
Urate only seen on USS or CT
How do you manage urological stones?
Mild, give analgesics and fluids and the stone may pass
Can alkalinise the urine for urate stones
Give bendroflumethiazide for calcium oxalate stones
May have to do lithotripsy to shatter stone
May have to perform laparoscopic/opens surgery to remove the stone if lithotripsy not effective
What are the RFs for bladder cancer?
Worked in a dye factory
Smoker
Woman
Over 60
What are the symptoms of bladder cancer?
Painless, frank haematuria
UTIs not resolving with antibiotics
Irritative urinary symptoms
What are the investigations for bladder cancer?
MSU to rule out infection
BT, for renal status and PSA
Flexible cystoscopy
CT TAP/urogram/PET to look for mets
How do you grade bladder cancer?
T1 - in the subendothelial
T4- spreading to other organs
N0-2 depending on number of lymph nodes involved
M0-1 depending on whether there is metastasis
How do you treat bladder cancer?
Look into surgical resection - TURBT
Radiotherapy
May need urostomy after urectomy
BCG can be used as immunotherapy
What are the types of UTI?
Simple - lower urinary tract = cystitis
Ascending - pyelonephritis
Recurrent = 3+ times a year
What are the symptoms of a UTI?
Burning on urination (dysuria) Frequency Urgency Haematuria Suprapubic/loin pain
Differentials for a UTI?
STI
PID
Appendicitis
Ruptured AAA
Investigations for a UTI?
Urine dip and MSU
USS for recurrent or complicated
Treatment for a UTI?
Antibiotics - trimethoprim/nitrofurantoin for 3 days
Can give prophylaxis for recurrent UTIs
RFs for BPH?
Over 60
Diet - soya is preventative
FHx
Pathophysiology of BPH
5-DHT is the active form of testosterone
With age and lots of this hormone, the prostate grows naturally
Most cells are under alpha-1 adrenergic control
Investigations for BPH
PSA Urine dip USS guided Biopsy IPSS: Asks about LUTS: -Straining -Nocturia -Incomplete voiding -Intermittency -Urgency -Weak stream -Frequency Then out of 35 - with higher being worse, 20+ is severe impact
Examinations for BPH
DRE
External genetalia
Abdominal exam
PSA testing for BPH
PSA will be raised in BPH
May also be raised due to: Ejaculation Recent exercise UTI Prostate stimulation Medications
Should repeat in 6 weeks/wait 4 weeks after an illness to test PSA
Biopsy for BPH
Need to take prophylactic antibiotics
6 specimens from each side of the prostate are taken
Treatment for BPH
Tamsulosin - alpha receptor blocker
Finasteride - 5 alpha reductase blocker, stops conversion of testosterone to 5-DHT
Gleason grading for prostate cancer
Most common grade and highest grade are added together to form an overall grade out of 10
Each specimen graded 1-5
Cancer is 6 and over
