Haematuria

Definition
 passage of red blood cell in the urine.
 can be detected by dipstick/frank blood.
 Frank haematuria (35% has urological malignancy).Therefore, frank haematuria, think
renal/bladder Ca.
Causes
Organ DDx Hx
Renal Glomerular disease Family Hx
Polycystic kidney Family Hx
Carcinoma Painful haematuria?loin pain?anorexia?weight loss?PUO
Stone Painful haematuria
Trauma(inc.Bx) Hx of trauma?Scan?
TB Hx or travel
Embolism
Renal vein thrombosis
Vascular malformation
UTI Fever,vomiting,loin pain
Ureter Stone Loin pain (stone)-colicky pain if obstructed, clot colic (neoplasm),
Neoplasm
Bladder Carcinoma Painless haematuria,pelvic pain, recurrent UTI, dysuria-
Stone (neoplasm), suprapubic discomfort (bladder stone), terminal
Trauma bleeding with pain (bladder stone)
Inflammatory eg. Total haematuria thru the stream-bleeding from bladder
Cystitis, TB, Terminal haematuria at the end of stream-rare but classical
schistosoma presentation of schistosomiosis.
Frequency, dysuria,urgency
Prostate BPH Terminal haematuria at the end of stream
Carcinoma Check for symptoms of prostatism-difficulty starting, poor stream,
nocturia
Urethra Trauma Urethral injury- pelvic # or falling astride or recent intercourse
Stone Urethral bleeding independent of micturation (urethral lesion)
Uretritis Initial haematuria at the start of stream-urethra
Neoplasm
Gen Anticoagulant Therapy Spontaneous bruising?
Thrombocytopenia Exposure to malaria?
Haemophilia Family hx
Sickle cell disease If young and fit-exercise?
Malaria
Strenuous exercise
Red urine Haemoglobinuria Crush injuries or ischemia of muscle
Myoglobinuria
Acute intermittent Take drug Hx, hx of malaria, TB
porphyria
Beetroot Ingestion?
Senna
 Phenolphthalein
Rifampicin

Examination

General weight loss,muscle wasting, cachexia,skin bruising/bleeding site

Chest coarse crackle, reduce air entry-TB, secondary deposits from carcinoma of
kidney

Abdominal mass palpable mass eg. Hypernephroma, distended bladder

Rectal examination smooth enlargement of prostate (BPH), hard craggy prostate (carcinoma)

Urethral examination Feel for stone, neoplasm

Muskuloskeletal bone tenderness-secondary deposit from carcinoma of prostate,
hypernephroma, bladder

Investigation

a)General Ix
Ix What we rule in/out?
FBC,ESR ↓Hb-gross haematuria,malignancy
↑Hb-polycytemia ass. with hypernephroma
↑WCC-infections
↓Platelets-blood dyscrasia
↑ESR-malignancy,TB
Urine Microscopy Red Cells-excludes haemoglobinuria and ingestions of substances that
cause discolouration of urine
White cells-infection
Organism-infection
cytology
MSU Culture and sensitivity -infection
U&E Renal failure
Clotting Screen Anticoagulant therapy, blood dyscrasia
CXR Metastases (cannonball metastases with hypernephroma),TB
KUB Renal calculus-80% of stone visible on Xray

Specific Investigation

Test Disesase for confirmation

PSA Prostatic carcinoma
Sickling test SCD
IVU Stone, tumour,TB,trauma
USS Cystic vs solid, stone, urinary tract obstruction/abnormalities
CT/MRI Tumour(conformation and degree of invasion),cyst,obstructive
 uropathy,stone (99% visible and better than IVU to detect stone;Good
TRO AAA if presentation is abdominal pain)
Cystoscopy Infection,tumour,stone
Uteroscopy Tumour,obstruction
Selective renal angiography Vascular malformation,tumour
Renal bx Glomerular disease,tumour
Prostatic bx Carcinoma of the prostate

Treatment: Depends on the causes

Disease Initial Management

Renal Stone Immediate analgesia eg. Diclofenac (IM/suppository) or pethidine IM with
metoclopramide IM +antibiotics.
Emergency Sx if renal obstruction shows by imaging
Renal tumour Radical nephrectomy for local diseas and immunotherapy
Ureteric tumour Referral for stenting to relieve obstruction ± resection of tumour
with/without nephrectomy/cystectomy depending on site.
Bladder tumour Depends on staging
T1-local excision by transurethral cystoscopy and diathermy followed by
intervesicular chemotherapeutic agents eg.mitomycin
T2-T3-radical cystectomy with post op chemo
T4-palliative chemo/radiotherapy
Bleeding diathesis If on warfarin and INr> 3.5, stop or adjust dose;if INR >> 3.5, vit K therapy.
Otherwise, detailed assessments of clotting /platelets abnormalities and
appropriate therapy.
Renal stones
 Due to crystal aggregates.
 Form in collecting duct.
 May be deposited anywhere from renal pelvis to urethra.
 Prevalence & incidence.
 Life time risk of 15%
 Peak age of onset is 20 – 40 years.
 Male: Female ratio of 3:1

 Types of stone
 Calcium oxalate 75%
 Magnesium aluminium phosphate. 10 – 20%
 Struvite
 Triple phosphate.
 Others.
 Urate 5%
 Hydroxyapatite 5%
 Cysteine 1%
 Brushite
 Mixed

Type Causative factors Appearance on X – ray

Calcium oxalate Metabolic Spikey
Idiopathic Radiopaque
Calcium phosphate Metabolic Smooth
Idiopathic May be large
Radiopaque
Magnesium aluminium UTI-recurrent Large horny (‘Staghorn’)
phosphate Radiopaque
Urate Hyperuricaemia Smooth
Brown
Radiolucent
Cystine Renal tubular defect, Yellow
Crystalline
Semi – opaque

 Clinical pictures
o May be asymptomatic.
o Pain.
Kidney Ureter Bladder/Urethral
loin pain renal colic pain on passing urine.
Radiates from loin to groin Poor urine flow.
Nausea Intermittent urine flow
Vomiting
Patient unable to lie still-in
peritonitis, pts lie still.

o Infection.
 Can co – exist with stones.
 Presents with.
Cystitis Pyelonephritis Pyonephrosis-pus Others
collect in renal pelvis
Frequency Fever Infected hydronephritis. Haematuria
Dysuria Rigors Protenuria
Loin pain Sterile Pyuria
Anuria
Nausea
Vomiting.

 In Hx
Diet Oxalate levels ↑-Chocolate,Tea,Rhubarb,Spinach
Time of the year Increased sunlight in summer increases Vitamin D synthesis, and so calcium and
oxalate levels
Occupation Can they drink freely?Is there risk of dehydration?
Drugs Loop diuretics, Antacids, Acetazolamide, Corticosteroids, Theophylline,Aspirin
Thiazide diuretics, Allopurinol, Vitamin C & D, Indinavir (HAART)
Risk factor Recurrent UTI- Magnesium aluminium phosphate stones.
Metabolic Hypercalciuria/Hypercalcaemia;Hyperparathyroidism
Abnormalities Neoplasia; Sarcoidosis;Hyperthyroidism
Addison’s syndrome,Cushing’s syndrome
Lithium, Vitamin D excess
Hyperuricosuria; Uraemia(alone /with gout)
Hyperoxaluria, Cystinuria,Renal tubular acidosis
Renal tract Horse shoe kidney, hydronephrosis, ureteral stricture, etc
abnormalities
Family history. Increases risk of stones 3X.
Specifically-ask
X – linked nephrolithiasis
Dent’s disease
 Proteinuria
 Hypercalciuria
 Nephrocalcinosis
Infection above the Fever, loin tenderness, pyuria
stone-urgent
intervention

Treatment
1. Analgesics ie. NSAIDS diclofenac 75mg IV/IM/suppository (100mg) or Morphine 5-10mg with
10mg metaclopromide.
2. Give fluids (if unable to tolerate orally) +antibiotics eg cefuroxime 1.5g/8H
3. If obstruction-----refer urologist for further management
Options
a) Extracorporeal Shockwave Lithotripsy (ESWL)
b) Percutaneous Nephrostomy to relieve obstructions
c) Uteroscopy±laser
d) Percutaneous nephrolithotomy
e) Open sx-rare

Renal Cell Carcinoma/Hypernephroma

Origin- Proximal convoluted tubule epithelium.
Epidemiology
-most common renal tumors in adult (90% of renal Ca)
- present mostly on 5th decade (mean age 55)
-M:F=2:1
-15% pts on haemodialysis dev RCC

Clinical Features
Most common Haematuria, loin pain, mass in flank
Others Malaise, weight loss, aneroxia,fever,
Occasionally polycytemia,
Varicocele (2%)- the enlargement of one testicle
25% have metastases at presentation to bone,liver,lung (Xray-cannonball
metastases)
Spread-direct(renal vein), lymph nodes and haematogenous.

Investigations
Blood FBC(polycytemia), ESR, U&E, alk phos
Urine RBCs,Cytology
Imaging USS, CT/MRI, IVU, renal Angiography, CXR,Bx for cell type

Treatment
Sx-radical nephrectomy gold standard -Unless bilateral involvement/contralateral kidney fx poorly
Metastatic disease medroxyprogesterone may control metastasis
Consider Immunotherapy with interferon α or interleukin 2

Prognosis=45% 5 year survival.

Bladder Tumour
 Commonest form of urological ca
  majority of Transitional Cell (urothelial)type
 other type includes adenocarcinoma and squamous cell carcinoma(may follow schistosomiasis)
 Common after age 40;M:F =4:1
 Spread-direct invasion to adjacent structure,lymphatic spread and haematogenous spread late.

Risk Factors
1. Smoking
2. Industrial chemical eg. Aromatic amines (rubber/dye industries)
3. Drugs eg. Phenacetin,cyclophosphomide
4. Chronic inflammation eg. Stone,Schistosomiosis-scc, chronic cystitis
5. Pelvic Irradiation
6. Bladder diverticulae
7. Persistent urchal remnant-adenocacinoma

Presentation
-painless haematuria, painful if clot retention,recurrents UTI and voiding irritability
-also dysuria,frequency,urgency

Examination
 usually –Ve in early stage.
 Tumour may be palpable on EUA

Investigation

Blood FBC-Hb↓,ESR↑,U&E
urine Creatinine, MSU & CS, urine microscopy&cytology (ca may cause sterile pyuria) ie WCC ↑, but
sterile culture.
Others Cystoscopy with Bx-diagnostic
IVU-filling defect, bimanual EUA-may help in staging,CT/MRI-lymph/pelvic nodes involvement

 Histology important for prognosis

Grade 1-well differentiated Grade2 –intermediate Grade 3-poorly differentiated

Stage Tumour location Ex under Anas Tx

Tis Ca in situ 1. Diathermy/endoscopic resection ±
Ta Tumour confined to intravesical Chemo (mitomycin) if high
epithelium impalpable grade 3/multiple tumour evidenced to
T1 Tumour in lamina propria ↓recurrence
2. High grade/ca in situ-immunotheraphy
with intravesical BCG may prevent
progression
NB: T1 has 70% chance of recurrence in 5 years
 and 10% of dev. Invasive disease.Hence do
cystoscopy at 6M/1Y interval for life!
T2 Superficial muscle involve Localize 1. Radical cystectomy-gold standard
rubbery 2. Post-op chemo eg
thickening cisplatin/methotraxate is toxic but
T3 Deep muscle involved Mobile mass effective
3. Radiotherapy has worse 5 years survival
than sx but bladder preserve
4. Formation of neobladder
-young, well motivated and high chance for cure
from cystectomy.
T4 Invasion beyond bladder;in Fixed mass 1. Palliative chemo(eg
pelvic cisplatin)/radiotherapy
2. Cystectomy for intractable bladder
symptoms
3. Chronic catherization/urinary diversion

Urinary Tract Infection (UTI)

Definition: Presence of pure growth of 105 of organism per ml of fresh MSU.

Sites: Urethra(uretharitis), bladder(cystitis),prostate(prostatitis),renal pelvis (pyelonephritis).
 Recurrent-further infection with new organism
Relapse-further infection with the same organism.

1/3 of women with symptoms has bacteriuria (abacterial cystitis/urethral syndrome)

Classification
Uncomplicated Normal renal tract and F(x)
Complicated Abnormal renal/GU tract,↓RFT,impaired host defences,virulent organism (stap.aureus),
men-until proven otherwise

Pathogenesis
Infection of UT usually via ascending transurethral route-facilitated by intercourse n catherization.
Women-more susceptible ?
1.short urethra
2.proximity to anus facilitates transfer of bowel organism to bladder.

Risk factors
Female, sexual intercourse,exposure to spermacide in female thru condom/ diaphragm,
pregnancy,menopause,↓ host defence, immunosuppression, DM, Urinary tract obstruction, stones,
cathether, UT malformations

Organism

Common E. coli (>70% in community, ≤41% in hospital),staph saprophyticus (10%),proteus mirabilis

(12%)
Rare Enterococcus faecalis, klebsiella,enterobacter,acinetobacter species,pseudomonas
aeruginosa,candida albicans, staph aureus

Symptoms

Cystitis Frequency, dysuria, urgency,strangury*,haematuria,suprapubic pain,

* a slowand painful discharge of urine drop by drop produced by spasmodic muscular contraction of
the urethra and bladder
Acute High fever, rigors, vomiting, loin pain & tenderness,oliguria (if ARF)
pyelonepritis
Prostatitis Flu like symptoms,low backache, few urinary symptoms, swollen/ tender prostate on PR
exam
NB: In elderly, symptoms may be atypical with incontinence,nocturia/just vague change in well being.

Signs
Fever, abdominal/loin tenderness,foul smelling urine (esp lower UT), may also present with distended
bladder,enlarged prostate.
NB :vaginal discharge esp. offensive one → check for foreign body ie.tampon! or STI
(candida,TV,BV,gonorrhea)

Test
Urine Dipstick Nirates and leucocytes +ve- treat empirically

MSU (C&S) Confirm infections and antibiotics sensitivity

Mandatory- male,child,
pregnant,immunosuppressed/ill,symptoms do not
resolve with one course of empirical antibiotics
Blood haematology FBC,WCC,ESR
biochemistry U&E,CRP
Microbiology Culture & sensitivity
Imaging USS/IVU/cystoscopy To look for physiological and anatomical abnormalities
KUB Xray

Indications for imaging

1. After a single UTI in children or men
2. Failure to respond to tx
3. Recurrent UTI ≥ 2 years
4. Pyelonephritis
5. Unusual organism
6. Persistent Haematuria
Also women with relapse (within 7 days of completions of antibiotics) & women with recurrence
infections (more than 2 in 6M) arising more than 2 weeks after tx.

Treatment

Conservative Drink plenty of H2O,urinate often

Specific Cystitis Trimetoprim 200 mg/12H PO (3D in F,7D In M) or
Cafalexin 1g/12H
2nd line: Ciprofloxacin/co-amoxiclav PO (7D)
Acute Cefuroxime 1.5g/8H IV then oral (7D)
Pyelonephritis
Prostatitis Ciprofloxacin (500mg/12H PO),4 weeks

Prevention
 Prophalaxis antibiotics,continous /post coital
 Drinking 200-750 ml cranberry/lingonberry juice /day@ take cranberry con concentrate juice
-↓10-20% infection.
Complications-more likely with complicated infections
1. Renal papillary* necrosis
2. Renal/perinephric** abscess with the risk of Gram –ve septicemia.
* renal papilla-location where Medullary pyramids empty urine into the renal pelvis
* cone-shaped retroperitoneal compartment containing the kidney, adrenal gland, perinephric fat, fibrous bridging septa, and a
rich network of perirenal vessel and lymphatics