Haematuria Flashcards
What is haematuria?
The presence of blood in the urine
Can be visible (i.e., frank) or invisible (i.e., microscopic)
What % of patients presenting with visible haematuria have an underlying malignancy?
14%
What % of patients presenting with non-visible haematuria have an underlying malignancy?
3%
What are the classifications of haematuria?
Visible haematuria - formerly “macroscopic” or “gross” haematuria = blood is visible in the urine, colouring it pink, red, or dark brown
Non visible haematuria - formerly “microscopic” or “dipstick positive” = blood is present in the urine but not visible
What 2 categories can non-visible haematuria (nVH) be further classified into?
Symptomatic NVH (s-NVH) = haematuria (confirmed on urinalysis/microscopy) presents with associated symptoms e.g., suprapubic pain or renal colic
Asymptomatic NVH (a-NVH) = haematuria (confirmed on urinalysis/microscopy) with no associated symptoms
What are the most common causes of haematuria?
UTI
Renal cancer
Bladder cancer
Prostate cancer
BPH
Name other less common causes of haematuria
Trauma
Radiation cystitis
Parasitic infection (most commonly schistosomiasis)
Name medical causes of haematuria
Glomerulonephritis (e.g., IgA nephropathy or post-infectious glomerulonephritis)
Thin basement membrane disease
Haemolytic uraemic syndrome
Multi-system disease (e.g., HSP or Goodpasteur’s disease)
What is pseudohaematuria?
Red or brown urine
Not secondary to the presence of haemoglobin
Name causes of pseudohaematuria
Meds e.g., rifampicin or methyldopa
Hyperbilirubinuria
Myoglobinuria
Certain foods e.g., beetroot or rhubarb
What are important things to remember in Hx taking for a patient presenting with haematuria?
Quantify degree of haematuria - pink vs dark red, clots or no clots
Timing in the stream - does the blood come all the way through the urine, at the start or at the end (total haematuria suggests bladder or upper tract source vs terminal haematuria which suggest potential severe bladder irritation)
Associated symptoms - e.g., Lower urinary tract symptoms (LUTS), fevers or rigors, suprapubic pain, flank pain, weight loss or recent trauma
DH and smoking status - strong association with smoking and urological malignancies
Any exposure to industrial carcinogens (increases risk of bladder cancer)
Recent foreign travel (increased risk of schisotomiasis from certain areas)
What can bright pink, orange, or dark brown coloured urine suggest?
Non-urological causes
Which examinations should you do in someone presenting with haematuria?
Abdominal exam
DRE
Examination of external genitalia
What investigations should be done?
Urinalysis - primary investigation - detects nitrites and/or leukocytes
Baseline bloods
FBC
U&E
Clotting
PSA
In people with deranged renal function or suspected nephrological cause, urinary protein levels (spot albumin:creatinine ratio or protein:creatinine ratio) may be warranted
Referral to nephrology may be need in patients with a likely nephrological diagnosis, evidence of declining GFR, severe chronic kidney disease, proteinuria with haematuria, or those < 40 years old with HTN
What are the current NICE guidelines for urgent referral to adult urology?
Aged ≥45yrs with either:
- unexplained visible haematuria with no UTI
- visible haematuria that persists or recurs after successful Tx of UTI
Aged 60 with:
unexplained non-visible haematuria
AND either
dysuria
OR
raised WCC on a blood test
Patients with asymptomatic non-visible haematuria on 2 out of 3 tests should also be referred for further investigation
What is the gold standard investigation for assessing lower urinary tract?
Flexible cystoscopy
Should be performed in all cases of haematuria where feasible
Often performed under local anaesthetic at a one-stop haematuria clinic
Some centres will also send urine cytology in the initial assessment for haematuria as a further adjunct assessment.
What other upper urinary tract imaging is warranted in cases of haematuria?
USS of the renal tract - typically done for cases of non-visible haematuria - cheap and non-invasive
CT Urogram - typically used for visible haematuria - provides more definitive imaging of the renal tract
What is the Mx of haematuria?
Treat underlying pathology
Review any anticoagulation
Correct any underlying blood clotting disorders
Blood transfusions as required
Inpatient admission under Urology for patients with significant haematuria, especially those in clot retention (acute urinary retention secondary to clots obstructing the bladder outflow) - these patients will need insertion of a 3-way catheter for ongoing washout and irrigation +/- evacuation of clots
Refractory visible haematuria (esp. in patients needing multiple blood transfusions) - rigid cystoscopy +/- under general anaesthetic may be needed to control the bleeding and treat the underlying cause
Sources
https://teachmesurgery.com/urology/presentations/haematuria/
https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer#urological-cancers
