Renal medicine and urology Hx's

Question 1

What are the are 2 types of presenting complaints of haematuria?

Answer 1

• frank haematuria
  
  • more likely due to a lower UTI lesion
  • 20-25% malignancy risk so more aggressively investigated than below
• microscopic haematuria
  
  • suggestive of glomerular disease
  • relatively more common
  • only pathological when recurring or associated with lower UTI symptoms

Question 2

What should be covered in HPC of haematuria?

Answer 2

CLOTS

CL- Clarify, when do you notice blood? passing urine? could it be from somewhere else? eaten beetroot?

O - onset, first noticed bloos?

T- timing, always blood in urine or does it come and go? had this before? blood present at start/end or throughout urination?

S- severity, do you pass any clots? [NB: presence of clots makes a glomerular cause more likely]

Question 3

What are the associated symptoms with haematuria?

Answer 3

1. pain (tummy, urethra, back - SOCRATES)
2. Frequency (urges/incontinence)
3. Nocturia
4. urinary stream (diff getting started, dribbling, powerful/weak stream)
   
   • poor urinary stream ~obstructive cause
5. constitutional (- unwell/feve/chills/appetite/weight loss)
6. Renal failure - recent weight gain, swollen ankles
7. gloperulonephritidies (acute/chron inflam of renal glomeruli capillaries) - sore throats/rashes or sore joints?
8. pulmonary-renal conditions ( oft. autoimmune)? - coughing blood
9. trauma to stomach or groin?

Question 4

What conditions should be specifically mentioned in a haemaaturia PMH and FH?

Answer 4

• PMHx: previous UTIs
• prostate/renal bladder cancer
• BPH
• diabetes
• hypertension

1. FAMILY Hx: renal disease inc polycystic kidneys
2. bleeding disorders
3. asymptomatic haematuria run in family (fam members also have blood in urine )

Question 5

What are the renal malignancies as DDx for haematuria?

Answer 5

• Renal cell carcinoma
  
  • Renal cell carcinoma (RCC) is a kidney cancerthat originates in the lining of the proximal convoluted tubule, a part of the very small tubes in the kidneythat transport primary urine.
• transitional cell carcinoma
  
  • Transitional cell carcinomas don’t start in the kidney itself, but in the lining of the renal pelvis (where the ureters meet the kidneys)

Question 6

What are the signs/symptoms of renal cell carcinoma?

Answer 6

• Triad: Flank pain, haematuria and an abdominal mass late presentation)
• Commonly found incidentally in pts with HTN or Anaemia
• constitutional Sx: weight loss, fever, fatigue
• may present w/paraneoplastic syndrome causing excessive renin, PTH or EPO

Question 7

What are the signs/symptoms of transitional cell carcinoma?

Answer 7

• Worrying = Painless, intermittend haematuria + in older MALES
• most common affected is bladder but can affect ureters or urethra too
• assoc w/ industrial dyes
  
  • but BIGGEST risk = smoking now in UK
  • Schistosomiasis is biggest bladder cancer cause elswhere e.g. africa (microscopic adult worms)

Question 8

What are the S/Sx of renal calculi?

Answer 8

1. Classical presentation = acute onset of excruciating flank/abdo pain; loin to groin radiation w/ N&V
2. renal colic pain is more constant than biliary/intestinal colic but often has periods of relief where dull ache only
3. often is asymptomatic and found incidentally
4. typically affects men in 30s-50s

Question 9

What are the S/Sx of UTI?

Answer 9

• cystitis triad: Urinary freq, urgency and dysuria
• fever, suprapubic pain and urethral discharge may also be present
• urine maybe cloudy with a foul odour and may contain blood
• more common in women, elderly
• only symptom maybe delirium

Question 10

What are the S/Sx of glomerulonephritis?

Answer 10

• can cause nephritis with frank haematuria or nephrotic syndroms
• many different causes:
  
  • associated preceding URTI (post streptococcal or IgA nephropathy)
  • haemoptysis (goodpastures syndrome)
  • systemic features e.g. rash (vasculitis)

Question 11

What are the other DDx for haematuria?

Answer 11

• [as well as UTI, renal calculi, glomerulonephritis, renal cell/transitional cell carcinoma]
• urinary tract injury
  
  • blunt, penetrating or iatrogenic (catheterisation)
• coagulopathy e.g. haemophilia
• prostatitis
• BPH and prostatic carcinoma (though haematuria not typically seen)
• beetroot (turns urine pink)
  
  • [NB: pts may not think pink urine is blood so be sure to ask urine colour if blood is denied]

Question 12

What investigations can be done for haematuria?

Answer 12

• UTIs = urinalysis, MC & S for UTI
• U&Es, FBC and clotting
• eGFR
• Autoantibody screen - ANCA (granulomatosis), ANA (SLE) and anti-glomerular basement membrane (attacks lungs too)
• bladder cancer = urine cytology and cytoscopy
• Masses = USS renal tract
• IV urography or CT scan if still no cause found
• glomerulonephritis confirm via renal biopsy

Question 13

What is the management of haematuria?

Answer 13

• frank haematuria –> urgent referral to urology or nephrology
• bladder cancer –> transurethral resection for superficial tumours; radical cystectomy and urinary diversion for invasive disease; possibly chemotherapy
• renal cell carcinoma - nephrectomy
• renal calculi - <5mm usually pass on own;
  
  • extra corporeal lithotripsy or endoscopic stone removal for medium size stones;
  • for larger stone removal = intracorporeal or open operations
• UTI - antibiotics e.g. trimethoprim in simple uncomplicated cystitis
• Nephrotic syndrome - treat cause; furosemide, ace inhibitors and Ca channel blockers to control fluid retention and HTN
• Rapidly progressive glomerulonephritis requires prompt treatment with high dose steroids and cyclophosphamide