Painless haematuria

Question 1

What are your differential diagnoses for the cause of the macroscopic haematuria?

Answer 1

• Bladder cancer – commonly associated with painless haematuria
• Renal cancer - may be painless haematuria or associated with loin pain
• Prostate cancer – more associated with microscopic haematuria
• Nephrolithiasis – calculi of urinary tract - renal, ureteric or cystic – less common in painless presentations
• Urinary tract infection – less likely in his gender and more associated with microscopic haematuria and dysuria
• Trauma e.g. recent catheterisation
• Kidney disease, glomerular bleeding

Question 2

What to ask in history taking for haematuria?

Answer 2

amount of bleeding, colour of urine, presence of clots, retention, relation of blood to stream
fevers
urinary symptoms: hesitency, terminal dribbling etc
urological history
surgically relevant comorbidities
medication Hx esp blood thinners
FHX
SHx smoking, exposure to industrial carcinogens

Question 3

What to do in the examination in haematuria?

Answer 3

• abdomen: tenderness, mass, enlarged bladder, renal angle tenderness
• PR

Question 4

What intervention can you do for haematuria while waiting for senior?

Answer 4

Insert 3-way catheter to allow for bladder washout

Question 5

What investigations to order for a patient with haematuria?

Answer 5

Bedside: urine dip and sample for MC&S – to rule out UTI. Microscopy may also identify malignant cells

Haematological: FBC, U&E, LFT, clotting, G&S/ cross-match, PSA if prostatic enlargement

Imaging: CT urogram, or ultrasound urinary tract

Special studies: cystoscopy +/- biopsy

Question 6

Investigations results reveal T2N0M0 renal cell carcinoma, what is the mainstay of treatment in this case?

Answer 6

Surgery is the mainstay of treatment (medical treatment e.g. immune therapies reserved for metastatic tumours) with treatment recommendations made in the Urology MDT. Procedures may include:
- Radical nephrectomy – open, laparoscopic/ robotic
- Nephron sparing nephrectomy

Question 7

Who would make up the Multidisciplinary Team (MDT) for the management of patient with renal cancer?

Answer 7

• Urologist
• Oncologist (with expertise in renal cancer)
• Pathologist
• Radiologist
• Specialist nurse
• Palliative care specialists
• MDT co-ordinator

Question 8

What would be the treatment if bladder cancer was identified?

Answer 8

• MDT
• CT staging
• Transurethral resection of bladder tumour for low grade tumours
• TURBT and chemo for high grade tumours
• invasive cancer - partial or radical cystectomy with pelvic lymphadenopathy, external beam bladder irradiation, systemic chemo
• metastatic - cisplatin based chemo

Question 9

How would you decide which patients to refer to urology?

Answer 9

• any pt >50 with microscopic haematuria
• any pt with frank haematuria