MANAGEMENT OF HAEMATURIA

Question 1

How do we split up the causes of haematuria?

Answer 1

Innocent (pseudohaematuria)

Pre-renal

Renal

Post-renal - Ureteric / Bladder / Prostatic / Urethral

Question 2

What are the innocent causes of apparent haematuria?

Answer 2

Haemoglobinuria

Myoglobinuria

Menstruation

Sexual intercourse

Acute intermittent porphyria

Beetroot, blackberries, rhubarb

Drugs: nitrofurantoin, senna, rifampicin, chloroquine and doxorubicin

Question 3

What are the pre-renal causes of haematuria?

Answer 3

Bleeding diathesis

Atrial fibrillation - warfarin therapy and embolism

Infective endocarditis

Scurvy

Purpura

Leukaemia

Thrombocytopenia

Haemophilia

Question 4

What are the renal causes of haematuria?

Answer 4

IgA nephropathy

Glomerulonephritis

Polyarteritis nodosa

Goodpasture’s syndrome

Acute pyelonephritis

Polycystic kidney disease

Haemolytic uremic syndrome

Alport’s syndrome

Question 5

What are ureteric causes of haematuria?

Answer 5

Calculus

Carcinoma

Papilloma

Schistosomiasis

Question 6

What are the bladder related causes of haematuria?

Answer 6

Cancer

Calculus

Cystitis

Injury

Purpura

Schistosomiasis

Ketamine abuse

Question 7

What are the prostatic causes of haematuria?

Answer 7

BPH

Cancer

Question 8

What are the urethral causes of haematuria?

Answer 8

Acute urethritis

Calculus

Injury

Carcinoma

Papilloma

Urethral meatal ulcer

Foreign body

Question 9

Who should be urgently referred on a two week wait basis for further investigations regarding haematuria?

Answer 9

All those with visible haematuria not associated with UTI or where symptoms recur or persist despite UTI treatment

Those aged 60 or over who have unexplained non-visible haematuria and either dysuria or a raised WCC

Question 10

Who should be non-urgently referred for further investigations regarding haematuria?

Answer 10

Aged 60 or over with recurrent or persistent unexplained UTI

Aged 40 or over with asymptomatic non-visible haematuria.

Patients under the age of 40 years with normal renal function, no proteinuria and who are normotensive do not need to be referred, unless they have symptoms not explained by UTI.

Question 11

What are the investigations that might be done in someone with haematuria?

Answer 11

Basic Obs

Urine dip

Urine microscopy

Urine albumin:creatinine ratio

FBC

ESR/PV (plasma viscocity)

U&Es

Clotting screen

PSA

KUB X-ray

USS

Cystoscopy under local anaesthetic

Question 12

What are the disadvantages of measuring PSA?

Answer 12

High reading has a low specificity eg BPH, UTI, ejaculation

May prompt unnecessary prostate biopsy, a procedure with significant morbidity

A low reading does not exclude prostate cancer

Question 13

When might you do a CT urogram in a patient who presents with haematuria?

Answer 13

If USS shows a mass lesion in the kidneys

Question 14

How is flexible cystoscopy performed?

Answer 14

Day patient case

Urine dip to exclude UTI

Antiseptic applied to glans penis or female urethral meatus

Injection of lignocaine gel into urethra

Introduce flexible cystoscope

Inspect urethra, prostate, bladder neck and bladder

Question 15

What is flexible cystoscopy good at diagnosing?

Answer 15

Bladder lesions such as transitional cell carcinoma

Cystitis

Bladder calculi

Urethral strictures

Prostatic obstruction

Question 16

What percentage of urinary tract stones are radio-opaque (and therefore picked up on x-ray)?

Answer 16

90%

Question 17

What is a complication of haematuria which can present as an emergency?

Answer 17

Clot-retention

Question 18

What is bladder clot retention?

Answer 18

A complication of bleeding into the bladder. A clot forms which then blocks the bladder outflow causing severe acute retention.

Question 19

How do we treat those with bladder outflow clot retention?

Answer 19

Admit to ward

Urethral catheterisation with an irrigating ‘three way’ catheter (20F size)

Rigid cystoscopy with transurethral resection of any tumours or diathermy of bleeding points.