Hematuria and Dysuria Flashcards
What is the definition of hematuria?
The presence of RBCs in the urine
Gross or microscopic
What else can cause urine to appear red or brown besides RBCs?
Myoglobinuria Porphyrinuria Dyes Drugs Pigments Metabolites
Red food dye Beets Blackberries Bile pigments Rifampin Phenazopridine Ibuprofen Salicylates Deferoxamine Precipitation or urate crystals in infants
What can cause a false-positive for blood on dipstick with a negative microscopy for RBCs?
Dehydration
Strenuous exercise
Oxidizing compounds - bleach or microbial perioxidase
Delayed reading of the dipstick
Differentiate between glomerular and non-glomerular blood in the urine
Glomerular
- Brown or tea-coloured urine
- RBC casts
- Dysmorphic RBCs
- Proteinuria
Non-Glomerular
- Bright red or pink urine
- Blood clots
- Normal RBC morphologic appearnace
- Blood at initiation or termination of urination
What is the most likely Dx for kids presenting with hematuria?
UTI or cystitis
Gross
- Glomerulonephropathies
- Trauma (with or without underlying anatomic abnormality)
- Nephrolithiasis
- Hypercalciuria
- Bleeding disorders
- Nutcracker Syndrome (Left renal vein entrapment)
Microscopic
- Most are self-limited and benign
Other sources
- Vaginal bleeding (menses, FB, infection, trauma)
- Rectal bleeding (fissure, hemorrhoid, trauma)
- Urethral prolapse
What is nutcracker syndrome?
Compression of the left renal vein between the aorta and the superior mesenteric artery before the renal vein joins the IVC
Usually present with:
- Unilateral flank pain
- Intermittent gross or microscopic hematuria
Dx by US or MRI
DDx of Hematuria in a child
GLOMERULAR Benign familial hematuria Cystic renal disease Glomerulonephritis - HSP - IgA nephropathy - Membranoproliferative GN - Membranous nephropathy - Polyarteritis nodosa - Post-streptococcal GN - Rapidly progressive GN - SLE - Wegener granulomatosis Goodpasture's disease HUS Hereditary nephritis (Alport syndrome) Interstitial nephritis Renal Vein Thrombosis
NONGLOMERULAR Chemical cystitis Coagulopathy or hemoglobinopathy Exercise Hypercalciuria Malignancy - Leukemia - Nephroblastoma - Neuroblastoma - Rhabdomyosarcoma - Wilm's tumor Medications Nutcracker syndrome Structural anomalies Trauma UTI Urolithiasis Vascular malformation
Why are kids more at risk for renal injury after blunt trauma?
Kidneys are lower and less protected from the ribcage/abdominal wall
More mobile
Larger kidneys
Kids have less protective perirenal fat and musculature
How do you evaluate kids with blunt abdominal trauma for renal injury?
UA for blood
- if macro (> 50 RBC/hpf) or gross - needs CT
Mechanism - rapid deceleration, direct flank trauma, falls from heights
Unstable patients
Need CT scan with IV contrast
Measure BP in all kids with hematuria
- if hypertension present - may be a renal emergency
What signs/symptoms associated with hematuria require urgent/emergent evaluation?
Gross hematuria Proteinuria Oliguria Dysuria Edema HTN Headache Fever Flank pain Abdominal pain Rash Recent sore throat or resp illness
Gross hematuria - needs workup for renal trauma, tumor, congenital abnormality or bleeding disorder
Proteinuria or systemic Sx- edema, oliguria, HTN, headache - ? glomerular disease
What are the indications for a renal/bladder US?
Gross hematuria (in absence of proteinuria or RBC casts)
- to evaluate for malignancy or cystic renal disease
Concern for:
Anatomic abnormalities
Obstruction
Nutcracker syndrome
What other bloodwork would be helpful in a workup for hematuria?
Urine dip and microscopy for all patients
BP for all patients
Urine Cx - for suspected UTI
CBC, BUN, Cr - for diagnoses that may impair renal function
AST/ALT, Albumin, Glucose, Bilirubin, Amylase and Lipase for trauma patients
INR/PTT - for bleeding disorders
Electrolytes, Complement (C3 and C4), Anti-streptolysin O, ANA, hepatitis screen and ESR - for concerns of nephritis
Positive dipstick for blood but neg microscopy - needs a CK and urine myoglobin for rhabdomyolysis
AND
Bilirubin for hemolysis
Name the causes of nephrolithiasis in children
Hypercalciuria (most common)
Genetic disorders
- Familial idiopathic hypercalciuria
- Bartter syndrome
- Distal RTA
Iatrogenic
- Loop diuretics
- Prednisone
Other:
- Infection with urease-producing organisms (Struvite or staghorn calculi)
- Cystinuria
- Hyperoxalinuria
- Protease inhibitor medications
- Ketogenic diet (high protein, low carb)
How do you diagnose urinary stones in children?
Complete Hx and PEx - including: Hx of UTIs, current meds, detailed FHx
90% have hematuria
Concurrent infection is common - UTI does not exclude Dx
Renal US - most accessible, no radiation, won’t detect small stones < 5mm
CT - most sensitive, but radiation
What are the most common causes of dysuria in kids?
UTIs Infectious cystitis (viral or bacterial) Urethritis (infectious, chemical or traumatic) Vaginitis Fused labia Balanitis Referred pain from perianal irritiation/pinworms Sexual abuse
Urethritis (infectious, chemical or traumatic)
- can be associated with other systemic diseases such as Steven-Johnson syndrome, Reiter Syndrome, Bechets syndrome
