Haematuria Flashcards by Jessica Lake

What type of cells make up the bladder urothelium?

Transitional cells

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What is the usual histology of bladder cancer?

Transitional cell carcinoma

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What less common type of bladder cancer usually arises from chronic irritation of the bladder?

Squamous cell carcinoma

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What bacteria are the commonest cause for Urinary Tract Infections (UTIs)?

Escherichia coli (E. coli)

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How much urine should an average adult produce per hour?

1-2ml/kg/hour

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What is oliguria? (2)

Urine output less than 1mL/kg/hr in infants, and less than 0.5mL/kg/hr in children and adults.
OR
Urine output less than 500ml in 24 hours, in children or adults.

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What are urinary stones most commonly composed of?

Calcium oxalate

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Which layers of the bladder lining can be affected in Non Muscle Invasive Bladder Cancer (NMIBC)?

Urothelium and lamina propria

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Which layer of the bladder lining need to be affected to classify a bladder cancer as Muscle Invasive Bladder Cancer (MIBC)?

Detrusor muscle (muscularis propria)

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What symptoms are indicative of urinary tract calculi (stones)? (3)

Loin-to-groin pain
Haematuria
Dysuria

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What is the main red flag symptom of bladder cancer?

Visible haematuria (in absence of UTI)

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How is nocturia defined?

Getting up to pass urine more than once during the night.

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What is phimosis?

Tight foreskin of the penis, seen often in children under 10; can cause problems in adults.

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What are the NICE urgent referral guidelines for bladder cancer? (3)

-Patient is aged 45 and over and has unexplained visible haematuria without UTI OR visible haematuria that persists or recurs after successful treatment of UTI
OR
-Patient is aged 60 and over and has unexplained non-visible haematuria AND either dysuria or a raised WBC count on blood test.

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What is the most accurate imaging technique that can be used for visualising urinary tract stones?

Non-contrast CT of the kidneys, ureters and bladder (CTKUB) - uses X-rays to detect stones containing calcium

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What urine dipstick result is considered to be non-visible haematuria?

At least ‘+’ of blood on a urine dipstick test on more than one occasion.

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What is the clinical significance of when during voiding haematuria occurs?

Blood at the start and/or end of voiding = bleeding likely originating from neck of bladder or below
Blood throughout (total haematuria) =bleeding likely originating from bladder and/or kidneys

Describe the classical symptom onset of pyelonephritis.

Often begins with symptoms of a lower urinary tract infection, followed by gradually increasing loin pain that is usually unilateral. Patient is often pyrexial and feels systemically unwell.

What urine dipstick results are highly indicative of a urinary tract infection (UTI)?

The presence of nitrates (a bacterial breakdown product) and leucocytes.

What is the next step following urine dipstick for investigation of a suspected urinary tract infection (UTI)?

Midstream urine sample (MSU) should be sent to the lab for microscopy, culture and sensitivity analysis.

[This takes 48 hours but is more accurate than a urine dipstick.]

What must a midstream urine sample (MSU) contain to be diagnostic of a urinary tract infection (UTI)?

Significant numbers of bacteria and white blood cells (more than 100,000 per ml in both cases).

What investigations should be done in suspected pyelonephritis? (4)

Send patient to emergency department
Urine dipstick test
Blood cultures and midstream urine samples sent to lab
Urgent upper tract imaging (CT or ultrasound) to exclude an obstructed, infected kidney

How should an obstructed, infected kidney be managed? (2)

‘Decompression’ - either by placement of a uteric stent (draining urine into bladder and thereby bypassing the blockage) or a nephrostomy (tube that passes from skin to renal pelvis of kidney, allowing it to drain directly into an external nephrostomy bag).

What are some non-kidney related differentials for patients presenting with loin pain and feeling systemically unwell? (3)

Appendicitis
Pelvic inflammatory disease
Ruptured abdominal aortic aneurysm

How should lower urinary tract infections (UTIs) be definitively treated? (1)

Antibiotics (depending on local guidelines and MSU sensitivity results) - usually given as 3-day course for women and 7-day course for men.

How should pyelonephritis and pyrexia be definitively treated? (2)

Usually 24-48 hours of IV antibiotics (such as gentamicin or co-amoxiclav) This is followed by a 10 day course of oral antibiotics (type dependent on local guidelines)

What is meant by the term ‘complicated UTI’?

There is an anatomical or pathological abnormality in the urinary tract that predisposes the patient to developing UTIs.

How should patients with suspected ‘complicated UTIs’ be investigated? (2)

Outpatient flexible cystoscopy AND ultrasound or CT scan of upper urinary tract.

How are ‘recurrent UTIs’ defined?

More than three episodes of infection per year.

How can recurrent UTIs be treated with medications if they are deemed troublesome? (3)

Long term low dose prophylactic antibiotics OR Patient can take one antibiotic tablet after sexual intercourse (if this is a causative factor) OR Patient can ‘self-start’ a 3-day course of antibiotics at onset of infective symptoms

What are the options for non-antibiotic management of recurrent UTIs? (5)

Cranberry extract (contains active compounds which may have antibacterial properties) D-mannose (a type of sugar taken as a supplement) Hiprex tablets (active ingredient is an antibacterial) Vaginal application of oestrogen creams (in post menopausal women) Good hydration

What is the classic triad of symptoms seen in pyelonephritis?

Vomiting, flank pain and fever.

What symptoms does bladder cancer usually present with? (3)

Visible/non-visible haematuria, dysuria or storage urinary symptoms in the absence of a UTI or recurrent UTIs that do not resolve with antibiotic treatment.

What investigation is usually used to identify bladder tumours?

Flexible cystoscopy (done under local anaesthetic in outpatient department).

What is the next step for a patient who has had bladder tumours identified?

Transurethral resection of bladder tumour (TURBT) - operation which scrapes the tumour out of the bladder (getting a sample from muscle layer to determine involvement). [Non-muscle invasive bladder cancer (NMIBC) are treated using this technique.]

What additional treatments can be given along with surveillance to help reduce recurrence and progression risks of Non-muscle invasive bladder cancer (NMIBC)? (2)

Intravesical instillations of chemotherapy agents (such as mitomycin) or intravesical BCG (BCG reduces progression to T2, muscle-invasive disease).

When is radical treatment required for bladder cancer?

If patients are T2 (muscle invasive) at diagnosis or progress from Ta/1 to this during surveillance.

What are the treatment options for Muscle Invasive Bladder Cancer (MIBC)? (4)

-Initial staging CT and MRI scans to check for metastases. -Total surgical removal of the bladder (radical cystectomy) -Radiotherapy -Both radical cystectomy and radiotherapy usually preceded by a course of chemotherapy.

How is bladder cancer graded? (Grades 1-3)

Grade 1 - least aggressive/ most well differentiated histologically Grade 2 - intermediately differentiated histologically Grade 3 - most aggressive/poorly differentiated histologically

In the UK, what is the most common chemotherapy agent to be instilled into the bladder via a catheter after a transurethral resection of bladder tumour (TURBT)?

Mitomycin (administered via a urinary catheter)

What is the transitional epithelium of the bladder made up of?

Multiple layers of epithelial cells which can contract or stretch.

According to the NICE guidelines for ‘low risk’ bladder cancer, how long is the surveillance period following a TURBT before a patient can be discharged back to primary care?

One year - they should have a flexible cystoscopy at 3 and 12 months post-TURBT, and can be discharged following this period if there is no disease recurrence.