Hematuria, Nocturia & Dysuria (King) Flashcards
What is the definition of hematuria?
3 or more red blood cells per high powered field in a spun urine sediment
How must a positive dipstick test be confirmed?
must always be confirmed with microscopic examination of the urine
What does it usually signal when hematuria presents with proteinuria?
moderate to severe kidney disease
What must be considered when a patient presents with hematuria?
malignancy (urothelial cell and renal cell carcinomas)
What are some risks for urinary tract malignancies? (kidney)
African American (kidney)
Analgesic abuse: phenacetin/acetaminophen
Family Hx
Obesity and HTN: kidney ca
What are some risks for urinary tract malignancies? (bladder)
White race (2X risk for bladder)
Schistosomiasis: bladder ca
Indwelling (foreign body) foley: bladder ca
Exposure to carcinogenic agents: cyclophosphamide, pioglitazone
Analgesic abuse: phenacetin/acetaminophen
Gross Hematuria
Visible red/brown color to the naked eye. ALWAYS requires investigation.
Microscopic Hematuria
Blood is detectable only on examination of the urine sediment by microscopy. Usually discovered incidentally.
80% patients asymptomatic patients have “idiopathic constitutional microhematuria” of no clinical significance.
Idiopathic constitutional microhematuria
Asymptomatic non-glomerular microhematuria. There’s no clinical significance.
What are some signs of glomerular bleeding as the source of hematuria?
Dysmorphic appearance of some RBCs
Proteinuria that is temporally related to the onset of hematuria
brown; cola-colored urine
What should you do if you suspect someone with glomerular bleeding?
Refer to nephrology for close monitoring or kidney biopsy. The kidney biopsy can be normal. Or it can show:
1. IgA nephropathy (most common)
2. Thin basement membrane disease (benign familial hematuria)
3. mild nonspecific glomerular abnormalities
4. Hereditary nephritis (Alport syndrome)
What are some endogenous non-glomerular sources of hematuria?
Nephrolithiasis
Cystitis, urethritis, prostatitis
Malignancy: renal cell carcinoma, bladder cancer, prostate cancer
GU mucosal injury by instrumentation
Trauma
Bleeding tendency
Exercise-induced hematuria
What are some exogenous sources of hematuria?
Contamination with blood (menstruation or factitious)
Endometriosis of the urinary tract
Repeat the urine evaluation
Explain the clinical approach to hematuria.
History, physical, and testing to rule out causes (menstruation) or source readily identified (UTI, Obstructive nephrolithiasis) - repeat testing for persistent hematuria
What is next if a patient with hematuria with unrevealing workup or persistent hematuria?
test for albuminuria, assess RBCs, measure BP and assess renal failure to rule out Glomerular kidney disease (will need a nephrology referral)
What is next if a patient with hematuria with unrevealing workup or persistent hematuria and is negative for glomerular kidney disease?
evaluate UPPER UT with CT Urography (CTU) if contraindicated MRU plus evaluate LOWER UT with urology referral for cystoscopy.
How should you evaluate pregnant patients with gross hematuria?
kidney and bladder ultrasound to rule out ureteral obstruction or urolithiasis.
If US shows hydronephrosis, MRU w/o contrast (further evaluation should be avoided, if possible, until after delivery.
Hematuria concurrent with polyuria and dysuria, +/- fever
consider infection
Hematuria with recent URI or symptoms of URI
postinfectious or infection-related glomerulonephritis (post-streptococcal glomerulonephritis)
Historical clues to hematuria
Positive family history of kidney disease
Unilateral flank pain, which may radiate to the groin
Hesitancy and/or dribbling in older men
Recent vigorous exercise or trauma
Travel or residence in areas endemic for Schistosoma haematobium or TB
Hematuria and bleeding from multiple sites
consider excessive anticoagulant therapy or bleeding disorder
Cyclic hematuria in women
endometriosis of the urinary tract (hematuria most prominent during or shortly after menstruation)
Hematuria with hx of meds such as NSAIDs, antimicrobials, PPIs and H2 blockers?
might be acute interstitial nephritis (typically with kidney function impairment)
African Americans presenting with hematuria
screen for sickle cell trait or disease (can lead to papillary necrosis)
What is the largest contributor to nephrolithiasis?
Family history (largest contributor)
Hyperparathyroidism
Calcium stones (80% of kidney stones)
What is the most common type of kidney stone?
Calcium stones (accounts for 80% of kidney stones)
What is the clinical presentation of nephrolithiasis?
Can be asymptomatic; symptoms usually from urinary obstruction include hematuria and unilateral flank pain radiating to the groin, n/v
How do you diagnose nephrolithiasis?
CT stone protocol; if pregnant then renal/bladder US with followup with MRU
What is treatment for nephrolithiasis?
Smaller stones require medical therapy: fluids, pain control, nausea control, expulsive therapy (alpha 1a blocker-tamsulosin or calcium ch blocker- nifedipine)
Larger and more complicated cases require surgical/ESWL therapies: extracorporeal shock wave lithotripsy (ESWL) or nephrolithotomy
What are the five type of kidney stones?
- Calcium oxalate monohydrate crystals
- Calcium oxalate dihydrate crystals
- Uric acid crystals
- Cystine crystals
- Struvite
Pathophysiology of dysuria
Sensory nerves located beneath the urothelium can be stimulated by chemical irritation or inflammatory conditions causing painful urination, burning, tingling, or stinging when voiding.
Differential Diagnosis of infectious inflammatory dysuria
Cystitis, Pyelonephritis, Prostatitis (in men), Epididymo-orchitis (in men), urethritis, vaginitis (very common in women)
STIs (test for Neisseria gonorrhoeae and Chlamydia trachomatis are indicated)
Differential Diagnosis of non-infectious inflammatory dysuria
Foreign body (stent/bladder stone)
Reactive arthritis Reiter syndrome
Idiopathic interstitial cystitis
Dermatological conditions (contact dermatitis/lichen sclerosis/lichen planus)
Differential Diagnosis of noninflammatory dysuria
BPH
Meds (spermacides)
Food (coffee/tea/alcohol)
Idiopathic bladder pain syndrome
What diagnostic test should you order for a patient suspected of dysuria?
A focused history, physical, and labs are usually adequate. (in women ask about vaginal discharge or irritation, recent menstrual period, and type of contraceptives used)
Dipstick urinalysis is the most useful test (imaging is not indicated)
What is important to include in the history of a female presenting with dysuria?
History should include vaginal discharge or irritation, most recent menstrual period, and type of contraceptives used
What imagining is indicated in a patient presenting with dysuria from a complicated UTI?
CT abd/pelvis with and without contrast
Uncomplicated UTI
Acute cystitis: infection presumed to be confined to the bladder in a non-pregnant patient
All other urinary infections are considered complicated. (Complicated UTI)
What is considered a recurrent UTI?
> 2 infections in six months or >3 infections in one year
Catheter-associated UTI (CA-UTI)
UTI associated with placement of urinary catheter or within 48 hours of removal
What are the most common causative agents of UTIs?
E. coli (75%)
others gram negs: Klebseilla, Pseudomonas and P. mirabillis
other gram pos: Enterococcus species, Staph. and Group B Strep
Classic presentation of cystitis?
Dysuria, Increased urinary frequency, and urinary urgency (sudden and strong desire to void bladder), suprapubic abd pain and either gross or microscopic hematuria
Classic presentation of pyelonephritis?
Dysuria, Increased urinary frequency, and urinary urgency, along with:
Fevers/chills/rigors
Flank pain
CVA tenderness on exam
Fatigue
N/V and anorexia
(altered mental status - common in older adults)
Diagnostic test for UTI?
Urine dipstick positive for leukocyte esterase and nitrites.
Urinalysis with urine microscopy: pyuria WBCs>2-5/HPF
Bacteria present
Urine Culture with sensitivities (true UTIs have >10,000 CFUs)
What is the first-line treatment for uncomplicated UTI (cystitis)?
Oral antibiotics:
Nitrofurantoin (5 days)
Trimethoprim-sulfamethoxazole DS (3 days)
Fosfomycin (single dose)
What is the second-line treatment for uncomplicated UTI (cystitis)?
beta lactams (5-7 days)
Fluoroquinolones - ciprofloxacin, levofloxacin; avoid in pregnancy
Treatment for asymptomatic bacteriuria?
No treatment is required unless pregnant (cephalexin, nitrofurantoin)
Treatment for complicated UTIs?
Hospitalized patient with IV antibiotics.
Outpatient patient with oral treatment
What are the most common causative agents of prostatitis?
E. coli (most common)
others gram negs: Klebsiella, Pseudomonas and P. mirabilis
other gram pos: Enterococcus species, normal skin flora
Classic presentation of acute bacterial prostatitis?
appear acutely ill (fever, chills, n/v, malaise), irritative voiding symptoms, obstructive symptoms, perineal pain often with deep perineal ache, can also see pain with ejaculation or blood in semen.
Classic presentation of chronic bacterial prostatitis?
more subtle signs and symptoms, some are even asymptomatic or have low grade fevers
Complications of prostatitis?
Bacteremia and sepsis
Epididymitis
Prostatic abscess
Chronic prostatitis
Chronic pelvic pain
Diagnosis of Prostatitis?
Digital rectal exam (DRE) - looking for prostate enlargement, tenderness or edema
Urinalysis and urine culture
Consider testing for gonorrhea and chlamydia
for chronic- diagnostic standard is prostatic massage
Treatment for Prostatitis?
Most are caused by gram neg bacterium:
fluoroquinolones - trimethoprim-sulfamethoxazole for 4-6 weeks
Nocturia
Waking at night to void, where each micturition is preceded and followed by sleep. Clinically meaningful is pt voids two or more times nightly.
Benign Prostatic Hyperplasia (BPH)
prostatic gland enlargement from increased total number of stromal and glandular epithelial cells
Lower Urinary Tract Symptoms (LUTS)
results from bladder outlet obstruction and resulting detrusor muscle overactivity.
Complications of BPH and LUTS?
Acute urinary retention, UTIs, acute or chronic renal failure (postrenal obstructive renal failure) due to hydronephrosis
Diagnostic test for BPH and LUTS?
AUA Symptom Index Questionnaire and DRE
Urinalysis and BMP (assess renal function)
With urinary retention - post-void residual or US (normal is <100ml)
Treatment for BPH and LUTS?
Patients with mild symptoms do NOT require treatment.
Moderate symptoms:
alpha 1 blockers (1-2 weeks) - can cause drop in BP
5 alpha-reductase inhibitors (6-12 months MUCH LONGER) - can decrease PSA, decrease libido, teratogenic
Anticholinergic agents (used in pts w/ overactive bladder w/o elevated PVR; can lead to outlet obstruction
Phosphodiesterase 5 inhibitors
AUA Symptom Index Questionnaire
Diagnostic test for BPH and LUTS used to quantify severity of symptoms
Surgical treatment for BPH and LUTS
Transurethral resection of prostate (TURP)
Simple prostatectomy
Note: urinary incontinence and erectile dysfunction are common complications after surgery.
