urology Flashcards
which is more concerning, gross or microhematuria
gross
describe an approach to hematuria
divide into:
- pre-renal
- -coagulation disorders
- -pseudohematuria (beets, dyes, laxatives) - renal
- -stones
- -trauma
- -tumours
- -infection
- -glomerulonephritis
- -vascular malformations - post renal
- -stones
- -trauma
- -tumours
- -infection
most likely cause of hematuria in age:
0-20 years
(in order of frequency)
glomerulonephritis
UTI
congenital anomalies
most likely cause of hematuria in age:
20-40 years
(in order of frequency)
UTI
stones
bladder tumour
most likely cause of hematuria in age:
40-60 years
(in order of frequency)
male–> bladder tumours, stones, UTI
female–> UTI, stones, bladder tumours
most likely cause of hematuria in age:
over 60 years
(in order of frequency)
male–> BPH, bladder tumour, UTI
female–> bladder tumour, UTI
what % chance is there that gross hematuria is a urological malignancy
25%
*gross, painless hematuria is malignancy until proven otherwise (trauma, infection, stones etc are generally symptomatic and picked upon hx)
what % chance is there that micro hematuria is a urological malignancy
5%
ddx of hematuria
most common are all pre or post renal
tumour trauma infections stones coagulopathy (doesn't cause gross hematuria)
things to ask on hx that suggest uro malignancy
weight loss night sweats flank pain N/V voiding changes
numer 1 risk factor for urothelial tumours
smoking
risk factors for urothelial tumours
smoking
occupational exposure (aniline dyes, hairdressers, painters, leather tanners)
meds (cyclophosphamide etc)
previous radiation exposure
chronic cystitis (catheters, infections)
what to ask on hx to evaluate stones
flank/abdo pain
dysuria
previous stones
what to ask on hx to evaluate uro infection
fever
chills
suprapubic or flank pain
dysuria
frequency
what investigations should you order to evaluate hematuria
- U/A and culture
- -leukocytes and nitrites suggest infection
- -dysmorphic RBCs with or without protein suggest glomerular cause or stones (maybe crystals)
- -C and S for infection - urinary cytology
- -collect specimen, more sensitive and specific depending on the grade of malignancy - CBC
- -hemoglobin and platelets (bleeding diathesis or coagulopathy?)
- -WBC for infection - PTT/INR
- -bleeding diathesis? - kidney function
what are the options for imaging the urinary tract
- ultrasound
- CT IVP/triphasic CT
- MRI
- IVP or retrograde pyelogram
- plain film KUB or CT KUB without contrast
for imaging the urinary tract:
pros of ultrasound
good for RENAL TUMOURS, STONES within kidney and hydronephrosis in the kidney
first investigation for microscopic hematuria (depends on risk category–> 40 yo or risk factors)
first step for signs of infection–> can do CT with contrast if there are findings
inexpensive and safe
for imaging the urinary tract:
cons of ultrasound
will miss ureteral stones, ureteral tumours and most small or flat bladder and renal tumours
may not differentiate blood clot from tumour in bladder or renal pelvis
no functional info
what is the first choice imaging test for patient with gross hematuria
CT IVP/triphasic CT
arterial/venous (later after injection)/excretory phase
image the ureters, kidney and bladder
contrast in the collection system can obscure views of stones tho
for imaging the urinary tract:
pros of CT IVP
most sensitive test for any GU pathology
accurate staging of renal/ureteric tumours and renal trauma
non contrast CT for patiens with renal colic
may demonstrate other disorders like abdominal aneurysm, ascesses, fluid collections, filling defects in the ureteric phase
for imaging the urinary tract:
cons of CT IVP
there can be adverse reactions to the IV contrast (allergy, nephrotoxicity)
expensive and has radiation exposure
contraindications for renal dysfunction, multiple myeloma, contrast allergy, pregnancy
can you use IVP or retrograde pyelogram for kidney tumours
no
what do you use IVP or retrograde pyelogram for
suspected stones or urothelial tumours of bladder and ureter
when do you use KUB or CT KUB without contrast in uro imaging
flank pain/renal colic–> good for ID stones (plain film will miss uric acid stones)