Haematuria Flashcards
What is haematuria?
The presence of blood in the urine. IT IS NEVER NORMAL.
Can be:
- Visible – seen by the naked eye
- Non-visible – confirmed by urine dipstick
Define visible haematuria
Blood visible in the urine, colouring it pink, red or dark brown.
Define non-visible haematuria
Blood is present in urine on urinalysis but not visible.
Divided into a further 2 categories:
- Symptomatic non-visible haematuria (s-NVH)
- Asymptomatic non-visible haematuria (a-NVH)
What is symptomatic non-visible haematuria (s-NVH) ?
Haematuria present with associated symptoms such as sub-pubic pain or renal colic
What is asymptomatic non-visible haematuria (a-NVH) ?
Haematuria with no associated symptoms
What is pseudohaematuria?
Red or brown urine that is not secondary to presence of haemoglobin.
Can be caused by:
- Medication (e.g. Rifampicin / Methyldopa)
- Hyperbilirubinuria
- Myoglobinuria
- Certain foods (e.g. beetroot and rhubarb)
What are the risk factors for haematuria?
- Smoking
- Recent infection
- Family history
- Cancers
- Unprotected sex (in men)
- Relevant travel Hx
What are the 5 most common causes of haematuria?
- Urinary tract infection (UTI)
- Urothelial carcinoma
- Stone disease
- Adenocarcinoma of the prostate
- Benign prostatic hypertrophy (BPH)
What are the broader causes of haematuria?
- Infection
- Malignancy
- Stones
- Renal disease
- Trauma
- Structural abnormalities
- Other
Also consider that many of these causes can occur at any point throughout the urological tract.
Give some specific examples of infectious causes of haematuria
- UTI
- Pyelonephritis
- Cystitis
- Prostatitis
- STIs (e.g. chlamydia)
Give some specific examples of malignant causes of haematuria?
- Urothelial cancer
- Adenocarcinoma of the prostate
- RCC
- Penile cancers
Give some specific examples of trauma that can lead to haematuria?
- Bladder trauma (e.g. pelvic fracture)
- Injury to renal tract
- Blunt renal injury
Give some specific examples of renal conditions that can cause haematuria?
- Glomerulonephritis
- IgA nephropathy
What are some specific structural causes of haematuria?
- BPH
- Polycystic kidney disease
- Renal vein thrombosis
Give other causes of haematuria / discoloured urine
- Menstruation
- Exercise
- Drugs
- Rifampicin
- Nitrofurantoin
- Cyclophosphamide
- Naproxen
- Schistosomiasis
What are the risk factors for schistosomiasis?
- Travel / migration from Africa, South America, the Caribbean, the Middle East and Asia.
- Swimming in fresh water in these regions
What are the causes of transient non-visible haematuria?
- UTI
- Menstruation
- Sexual intercourse
- Vigorous exercise
What are the causes of persistent non-visible haematuria?
- Cancer
- Stones
- BPH
What would you want to ask about haematuria as a presenting complaint?
- Assess the degree of haematuria
- Colour of urine?
- Clots?
-
Timing in the stream
- Constant? Sporadic?
- Total haematuria suggests bladder / upper tract source
- Terminal haematuria potentially severebladder irritation
-
Associated symptoms
- Lower Urinary Tract Symptoms (LUTS)?
- Fevers or rigors?
- Suprapubic / flank pain?
- Weight loss?
- Recent trauma?
Once you have gained a full understanding of the history of presenting complaint, what are important points to note in the rest of the history?
- Drug history
-
Smoking status
- Increased risk of urological malignancies
- Exposure to industrial carcinogens
- Increased risk of bladder cancer
- Recent foreign travel
- Increased risk of schistosomiasis
How are you going to examine a patient presenting with haematuria?
- Abdo exam (inc balotting kidneys & palpating bladder!)
- DRE +/- Examination of external genitals
What initial investigations would you order to investigate haematuria?
-
Urinalysis (Dipstick)
- Nitrites / leukocytes may indicate infection
-
FBC
- Assess infection / anaemia
-
U&Es
- Assess kidney function
-
Clotting
- Assess bleeding status
-
PSA (after appropriate counselling)
- When prostatic pathology is a possible cause of haematuria.
-
Urinary protein levels (albumin:creatinine ratio or protein:creatinine ratio)
- In those with deranged function / suspected nephrological cause
What value on a dipstick is classified as haematuria?
≥1+ blood constitutes haematuria
IT’S NOT HAEMATURIA WITH ‘TRACE’ BLOOD
What specialist investigations would you order?
-
Flexible cystoscopy = Gold standard for assessing the lower urinary tract (EVERY CASE SHOULD HAVE ONE)
- Under local anaesthetic
-
Urine cytology (sometimes)
- More commonly used in follow-up of patients with proven malignancy, but can be used in the initial assessment
-
US KUB
- Cheap and non-invasive method
- Typically used for non-visible haematuria
-
CT Urogram
- More definitive imaging but higher radiation exposure
- Typically used for visible haematuria
