HEMATURIA

BYDR.MOHAMED ASHRAF MOSTAFA

MS.FRCS

HEMATURIA• Definition : presence of blood in the urine.• The passage of blood in the urine is

always alarming and investigation is warranted.

COMMON CAUSES OF RED URINE

• Hematuria.• Hemoglobinuria, myoglobinuia.• Anthrocyanin in beets and blackberries.• Chronic lead and mercury poisoning.• Phenolphthalein (in bowel evacuants).• Phenothiazines (compazine).• Rifampicin.

TYPES OF HEMATURIA

MACROSCOPIC (Gross)

MICROSCOPIC: SYMPTOMATIC ASYMPTOMATIC(with (proteinuria or isolated)

INITIALTERMINAL

TOTAL

CAUSES OF HEMATURIA

MEDICAL

UROLOGICAL

MEDICAL CAUSES OF HEMATURIA

NephrologicalIg nephropathy, post

Infectious g.n.Less commonly,membrano-proliferative g.n.,H.S.purp

Coagulationdisorders, hemophilia

anticoagulants.S.C.disease, renal pap.

necrosis, vascular disease,emboli to kidney

UROLOGICAL CAUSESCANCER: Bladder (TCC,SCC), Kidney (adeno-

carcinoma), Renal pelvis & ureter (TCC) Prostate.

Stone disease : kidney, ureter, bladder

Infection: bacterial, parasitic(schistomiasis)Inflammatory: drug induced e.g.cyclophosphamide

interstitial cystitis.Trauma: kidney, bladder, urethra

Renal cystic disease, vascular malformationsBPH

IS MICROSCOPIC HEMATURIA ALWAYS ABNRMAL?

• A few RBCs can be found in urine of normal people.• 40% of soldiers has mic.hematuria on at least one

occasion and 15% on 2 or more occasions.

Transient hematuria: •Rigorous exercise,Sexual intercourse orMenstrual contamination.

DIAGNOSIS OF HEMATURIAHISTORY

• Age and sex.• Smoking.• History of schistomiasis in endemic areas.• Occupational exposure to carcinogens.• Drugs e.g. NSAID, Cyclophosphamides.• Pain, fever, dysuria, frequency.• History of clots suggests extraglomular cause.• History of recent throat pain suggests post

infectious g.n.• Information about exercise, menstruation recent

catheterization or passage of calculi.

COMMON CAUSES OF HEMATURIA BYAGE& SEX

• 0-20 yr : Acute glomerulonephritis Acute UTI Congenital UT anomalies with obstruction• 20-40 yr Acute UTI Stones Bladder cancer

COMMON CAUSES OF HEMATURIA BY AGE& SEX

• 40-60 yr (men) bladder tumor Stones Acute UTI• 40-60 yr (women) Acute UTI Stones Bladder tumor• 60 yr BPH (men) Bladder tumor Acute UTI

Risk Factors for Significant Disease in Patients with Microscopic Hematuria

Smoking historyOccupational exposure to chemicals or dyes (benzenes or aromatic amines)History of gross hematuriaAge >40 yearsHistory of urologic disorder or disease

DIAGNOSTIC APPROACH OF HEMATURIAPHYSICAL EXAMINATION

• BP• General exam. : peripheral edema, petichiae. Skin rashes and arthritis can occur in

Henoch-Schönlein purpura and systemic lupus erythematosus CVS : irregular cardiac rhythm,

murmur or hypertension. • Abdomen : organomegaly or flank mass.• Ext. genitalia : meatal stenosis, phimosis, urethral discharge.• DRE : prostate.

DETECTION OF HEMATURIA • Urine dipsticks test

- Urine dipsticks test for

presence of hemoglobin & myoglobin in urine .

- Hem catalyses the oxidation of orthotolidine by organic peroxidase producing a blue colored compound.

- Dipsticks are capable of detecting the presence of hemoglobin from 1 or 2 RBCs.

DIPSTICKS TESTS

• False positive results : Myoglobinuria, Bacterial peroxidases, Povidine & hypochlorite.

• False negative results (rare): Reducing agents ( e.g. ascorbic acid which

prevents oxidation of orthotolidine.(

LABORATORY STUDIES

Urine microscopyFresh specimen:

Pyuria suggests infection/inflammation. RBC casts suggest GN .

Dysmorphic RBC suggests renal origin

Urine c/s

LABORATORY STUDIES

1 .24 hours urine proteins 2 .Low serum complement

- postinfectious glomerulonephritis, systemic lupus erythematosus nephritis, bacterial endocarditis, and membranoproliferative glomerulonephritis

3 .Antinuclear antibody (ANA) and double-stranded DNA

-systemic lupus erythematosus nephritisBUN & S. Creatinine

LABORATORY STUDIES

Urine cytology : -Detects 95% of grade III and invasive bladder

tumors. Sensitivity decreases for upper tract disease.

- In pts with higher risk of bladder cancer like older, smokers, long-standing cyclophosphamide, negative cytology should be followed by cystoscopy.

IMAGING STUDIES

Renal and bladder ultrasonographySpiral CTVoiding cystourethrographyRadionuclide studies

ULTRASONOGRAPHY

Urinary tract neoplasm, stone disease,

inflammatory processes, congenital abnormalities, vascular lesions, and obstruction

Not likely to detect non obstructing ureteral stones or small urothelial abnormalities,

CT SCAN

INTRAVENOUS UROGRAPHY

MRI UROGRAPHY

Currently serves as an alternative imaging technique for children and pregnant women and for patients with a contraindication to iodinated contrast media.

Urothelial cancers, stones, renal tumors

VOIDING CYSTOURETHROGRAPHY

Congenital abnormalities of UT

CYSTOSCOPY

Recommended for higher risk patients.

If find lower tract disease on cystoscopy , the upper tracts should also be evaluated

RENAL BIOPSY

Rarely indicated in the evaluation of isolated asymptomatic hematuria.

Relative indications are as follows: 1.Significant proteinuria2.Abnormal renal function

3.Recurrent persistent hematuria4.Serologic abnormalities (abnormal complement,

ANA, or dsDNA levels)5.Recurrent gross hematuria

6.A family history of end-stage renal disease

Peditric

Adult patient with asymtomatic mic. Hematuria

SUMMARY

• The passage of blood in the urine is always alarming and investigation is warranted.

• Urine microscopic exam. Should be carried out in all cases of +ve dipstick test

• Evaluation must be started with detailed occupational, family and medical history

• Medical causes should be excluded before urologic consultation

• U/S and CT scan are much helpful for evaluation of patients with hematuria

SUMMARY

• Urine cytology and cystoscopy are included in the work up for high risk patient group

• No abnormality is found in up to 70% of patients with asymptomatic microscopic hematuria despite full conventional urologic investigation( urine cytology, cystoscopy, ultrasonography and IVU)

THANK YOU