Haematuria: Urological Emergencies

Question 1

How can haematuria be classified?

Answer 1

Macroscopic (visible) or microscopic ((non visible)

Non visible is picked up on urine dipstick or mid stream urine sample

The darker the colour, requires need for patient admission

Question 2

Which criteria does a patient need to meet for a 2 week wait urology referral?

Answer 2

~ unexplained VISIBLE haematuria without UTI

Or

~ Visible haematuria that persists after successful treatment of UTI

Or

~Aged 60 and over and unexplained NON VISIBLE haematuria AND either dysuria or raised WBC

Question 3

When would you consider a non urgent referral for bladder cancer in people aged 60 or older?

Answer 3

If they have recurrent or persistent unexplained UTI

Question 4

Common causes of haematuria ( related to bladder, ureters, kidneys, prostate, vagina, pseudo haematuria )

Answer 4

KIDNEYS: pelvi-calyceal: transitional cell carcinoma, stones)

URETERS: Transitional cell carcinoma, stones

BLADDER: UTI, Transitional Cell Carcinoma, Stones, Cystisis (inflammation of the bladder usually during infection), Other cancers

PROSTATE: Malignancy, Benign Prostatic Enlargement (enlargement of the prostate gland), Prostastis (inflammation of the prostate gland)

URETHRA: transitional cell carcinoma, trauma

VAGINA: ALWAYS RULE OUT VAGINAL BLEEDING AS A CAUSE !!!!

PSEUDO- HAEMATURIA: Rifamycin, beetroot

Question 5

Intial management of visible haematuria

Answer 5

• ABCDE
• Oxygen
• Gain IV access
• Bloods (FBC, renal function, clotting etc.)
• Fluid +/- blood resuscitation
• 3 WAY CATHETER
• Mid stream /catheter urine sample
• History , examine, admit and inform senior

CONSIDER STARTING BLADDER IRRIGATION VIA 3 WAY CATHETER AND MABYE BLADDER WASHOUTS ON THE WARD

Question 6

Further investigations for haematuria

Answer 6

1. Ultrasound:

• fast
• no radiation
• user dependant
• may miss small tumours and stones

2. CT scans:

• greater sensitivity and specificity
• radiation

Question 7

What is a CT urogram and why is it used

Answer 7

taken in a delayed phase after the intravenous contrast has been given to visualise the urinary tract- highlights the kidney, ureters and bladder

Question 8

Causes of transient or spurious non-visible haematuria

Answer 8

urinary tract infection
menstruation
vigorous exercise (this normally settles after around 3 days)
sexual intercourse

Question 9

Causes of persistent non-visible haematuria

Answer 9

cancer (bladder, renal, prostate)
stones
benign prostatic hyperplasia
prostatitis
urethritis e.g. Chlamydia
renal causes: IgA nephropathy, thin basement membrane disease

Question 10

testing for haematuria

Answer 10

• urine dipstick is the test of choice for detecting haematuria
• persistent non-visible haematuria is often defined as blood being present in 2 out of 3 samples tested 2-3 weeks apart
  renal function,
• albumin:creatinine (ACR) or protein:creatinine ratio (PCR) and blood pressure should also be checked
• urine microscopy may be used but time to analysis significantly affects the number of red blood cells detected

Question 11

when should patients with haematuria be urgently referred?

Answer 11

Aged >= 45 years AND:
unexplained visible haematuria without urinary tract infection, or
visible haematuria that persists or recurs after successful treatment of urinary tract infection

Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test

patients under the age of 40 years with normal renal function, no proteinuria and who are normotensive do not need to be referred and may be managed in primary care