- blunt/ penetrating - beware minor trauma to pathological kidney e.g hydronephrosis <--- PUJ obstruction Paeds

- acute hemorrhagic cystitis - TB - schistosomiasis/ biliharzia

Hematuria Flashcards by Boikhutso Sekgobela

What is the definition of hematuria?

Hematuria is the passage of more than 3 red blood cells (RBCs) per high power field (HPF) on urine microscopy.

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Why might females confuse hematuria with other types of bleeding?

Females may confuse hematuria with vaginal or rectal bleeding due to the anatomical proximity of the urinary, vaginal, and rectal openings.

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Are male patients typically able to describe the relationship between micturition and bleeding?

Yes, male patients are generally able to describe the relationship between micturition (urination) and bleeding more accurately than females.

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What is microscopic hematuria?

Microscopic hematuria is an incidental finding during a routine medical exam, detected by dipstick screening and confirmed by microscopy showing >3 RBCs/HPF.

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What is macroscopic hematuria and what should be considered?

Macroscopic hematuria is visible to the naked eye, ranging from dark urine to frank blood or clots. Food and medication effects should be considered as possible causes of discoloration.

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What is initial hematuria and where is its origin?

Initial hematuria is blood visible at the beginning of micturition that then clears. Its origin is typically the urethra.

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What is total hematuria and where is its origin?

Total hematuria is blood visible throughout the entire process of micturition. Its origin is usually from the upper urinary tracts or bladder.

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What is terminal hematuria and where is its origin?

Terminal hematuria occurs at the end of micturition. Its origin is typically the bladder or prostate, and it is a classical presentation of schistosomiasis.

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What are the nephrological causes of hematuria?

Nephrological causes of hematuria include:

2–3+ proteinuria
Dysmorphic red blood cells
Red cell casts
Glomerulonephritis
IgA nephropathy

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What are the hematological and urological causes of hematuria?

Hematological and urological causes of hematuria include:

No proteinuria
Normal RBCs
No red cell casts
White cell casts (acute pyelonephritis)
Hematological causes (e.g., Warfarin, blood dyscrasias)
Urological causes

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Urological causes: Kidney

trauma
infection
renal tumor
renal stone
polycystic kidney disease
vascular

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kidney trauma

blunt/ penetrating
beware minor trauma to pathological kidney
e.g hydronephrosis <— PUJ obstruction
Paeds

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infection of the kidney

acute pyelonephritis
TB
-Schistosomiasis

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Renal tumors

benign
malignant

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kidney: vascular causes of hematuria

renal vein thrombosis
AV fistula

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What are the urological causes of hematuria related to the ureter?

Urological causes of hematuria related to the ureter include:

Ureteric stone
Ureteric tumor

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Urological causes: Bladder

trauma
infection
bladder cancer
bladder calculus

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bladder trauma

blunt
penetrating

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bladder infections

acute hemorrhagic cystitis
TB
schistosomiasis/ biliharzia

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bladder cancer

commonest cause of painless macroscopic hematuria in older patients
SMOKING = RISK

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Bladder calculus

bladder outlet obstruction
neuropathic
foreign body

What are the urological causes of hematuria related to the prostate?

Benign Prostatic Hyperplasia (BPH)
Carcinoma of the prostate

What are the urological causes of hematuria related to the urethra?

Trauma
Carcinoma

What are the types of hematuria?

Microscopic
Macroscopic
Initial (at the start of urination)
Terminal (at the end of urination)
Total (throughout urination)

What associated symptoms and history should be considered in a patient with hematuria?

Pain: Specify if present Symptoms of Anaemia: Specify if present Symptoms of Urinary Retention: Specify if present Previous Medical History: - Renal calculi - Malignancies - Blood dyscrasias Medications: - Warfarin - Drugs that alter urine color (e.g., Rifampicin, Senna)

What social history factors are relevant in a patient with hematuria?

Smoking: Yes/No Travel History: Schistosomiasis exposure

What are the major risk factors for bladder cancer?

Tobacco Smoking (+++++): Exposure to aromatic amines and other carcinogens (tar, hydrocarbons) Occupational Exposure: -Aromatic amine manufacture (+++++) - Dye/Staff manufacture (+++++) - Rubber industry (++) - Painting (+) - Leather industry (+) - Aluminium industry (+) - Truck drivers (++) – Diesel exhaust and reduced bladder voiding

What drugs increase the risk of bladder cancer?

Phenacetin (+++++) Cyclophosphamide (+++++)

What urinary tract diseases are risk factors for bladder cancer?

Schistosoma infection (+++++) – Chronic inflammation, altered metabolism Cystitis (+) Urinary stones (+)

What environmental and genetic factors are linked to bladder cancer?

Carcinogens in drinking water (arsenic, chlorination by-products) (+) Decreased fluid intake (?) – Less dilution of carcinogens, decreased voiding frequency Genetic polymorphisms (NAT1, NAT2, GSTM1) (?) – Genetic predisposition Coffee (?) Artificial sweeteners (?)

What general examination findings are significant in hematuria?

Signs of Systemic Illness: - Pyrexia - Tachycardia - Pallor - Oedema - Recent weight loss Clinical Considerations: - ? Symptomatic anaemia - ? Haemodynamic instability

What abdominal examination findings are relevant in hematuria?

Findings: - Mass - Hepatomegaly - Splenomegaly - Palpable kidney - Palpable bladder Clinical Considerations: - ? Clot retention - ? Organomegaly due to primary tumour or metastases

When are rectal and pelvic examinations indicated in hematuria?

Prostate – ? Prostate cancer or BPH Cervix – ? Cervical cancer Vagina – ? Local advanced pelvic malignancy Rectum – ? Rectal cancer

What genital examination findings are relevant in hematuria?

Urethral/Penile Lesions – Check for abnormalities

What findings on urine microscopy are relevant in hematuria?

>3 RBC/HPF – Confirms diagnosis of hematuria Dysmorphic RBCs – Suggests nephrological cause Red cell casts – Indicates nephrological origin White cell casts – Associated with pyelonephritis Ova – Suggests schistosomiasis (send sample "after tea")

What are the guidelines for urine culture in hematuria?

Collect before antibiotic administration Use midstream urine sample

How is TB investigated in cases of hematuria?

Collect early morning urine x 3 for TB culture

When should INR be checked in hematuria patients?

Patients on Warfarin Clinically suspected coagulopathy

Should patients on anticoagulants with high INR be investigated for hematuria?

Yes, fully investigate even if INR is high at presentation

When should special investigations be done in hematuria patients?

All patients with persistent microscopic hematuria All patients with macroscopic hematuria Exception: Very low-risk patients

Who are considered VERY LOW RISK in hematuria?

Young, asymptomatic females (<40) Microscopic hematuria No risk factors for malignancy

What are the minimum special investigations for hematuria?

Cystoscopy Upper tract imaging: - Ultrasound - Intravenous pyelogram - CT scan

What is the ideal investigation for suspected calculi in hematuria?

Uncontrasted CT is ideal.

What is the recommended investigation for suspected renal tumour or upper tract TCC in hematuria?

A 3-phase contrasted CT is recommended.

What is the current recommendation regarding urine cytology for screening in hematuria?

Urine cytology is no longer recommended for screening in hematuria.

What further investigations should be considered in patients with recurrent macroscopic hematuria and normal initial investigations?

Consider ureteroscopy, retrograde pyelography, and angiography.

What should be considered when managing hematuria in terms of blood loss?

Consider the systemic effects of blood loss, including shock and anemia.

How should shock or anemia associated with hematuria be managed?

Identify and manage shock and anemia promptly.

How should warfarin toxicity and coagulopathy be managed in the context of hematuria?

Address warfarin toxicity and coagulopathy with appropriate reversal and supportive measures.

What is the management approach for clot retention in hematuria?

Identify urinary retention and use a large bore, 3-way catheter to drain the bladder and allow bladder irrigation.

What is an important consideration regarding supra-pubic catheters in hematuria management?

Avoid supra-pubic catheters to prevent upstaging and tumour tract seeding in bladder cancer.

Why is it important to facilitate expedited investigation in patients with hematuria?

Delays in the investigation of suspected bladder TCC (Transitional Cell Carcinoma) can affect outcomes, even if delayed by a few weeks.