Haematuria Dr. Abdelmoniem E. Eltraifi Consultant Urologist College of Medicine & KKUH King Saud University, Riyadh, Kingdom of Saudi Arabia
Case 1 42 years old male, under your follow up for DM. During his routine follow up appointment. Told you that:
He had an episode of gross haematuria, one month ago. He want to a private clinic near his house. They gave him an IV fluids. They did for him: MSU and urine culture, which he showed to you, with only +ve uncountable RBCs.
Following that single episode, he had a clear urine. His history other wise unremarkable apart from DM
What you will do for him? Reassurance. Follow up. Further work up.
What will you do First? Urine analysis. Other Investigations.
If his urine analysis came clear, with nil RBCs Will you do: Reassurance Follow up? Further investigations?
What investigations? Urine Cytology Repeat US of the kidneys and pelvis. IVU CTU
If CTU and urine cytology were –ve. Are you going to do: Further investigations? Follow up? Reassurance?
Haematuria Prevalence of Haematuria ranges from 2.5% to 20%
Haematuria classified into: Gross, Macroscopic Symptomatic ( Painful) or Asymptomatic ( painless) Microscopic, invisible Also Symptomatic ( Painful) or Asymptomatic ( painless)
Microscopic: 3 or more RBCS/High power, in 2 out of 3 properly collected samples ( AUA). Prevalence ranges from 0.19% to 16.1%. Neoplasm of genitourinary tract (GU) found in about 3-5% of asymptomatic patients. No identifiable cause in about 40%.
Gross ( Macroscopic, Visible, Clinical): 1 ml of blood in 1 liter of urine is visible for the patients.
22 to 40% of patients presented with asymptomatic gross haematuria are found to harbor GU neoplasm.
Causes of Haematuria Varies according to: Patient Age Type: Gross or Microscopic Symptomatic or Asymptomatic The existence of risk factors for malignancy.
Causes of Haematuria… Urinary tract malignancy Urothelial cancer Renal cancer Prostate cancer
Causes of Haematuria… Urinary tract infection Urinary calculi Benign prostatic hyperplasia Radiation cystitis and/or nephritis Endometriosis & Vesico-Uterine Fistula Urethral polyps
Causes of Haematuria… Anatomic abnormalities Arteriovenous malformation Urothelial stricture disease Ureteropelvic junction obstruction Vesicoureteral reflux Nutcracker syndrome
Causes of Haematuria… Medical or renal disease Glomerulonephritis Interstitial nephritis Papillary necrosis Alport syndrome Renal artery stenosis
Causes of Haematuria… Metabolic disorders Coagulation abnormalities Hypercalciuria Hyperuricosuria
Causes of Haematuria… Miscellaneous Trauma Exercise-induced hematuria Benign familial haematuria Loin pain–haematuria syndrome
Causes of Red-Orange urine discoloration Red colored candy and drinks
Transient Microscopic Haematuria could be due to: • Vigorous Exercise • Sexual Intercourse • Viral infection • UTI • Mild Trauma • Menstrual Contamination
Risk factors for Urothelial cancer in patients with microscopic haematuria Smoking history Occupational exposure to chemicals or dyes (benzenes or aromatic amines) History of gross haematuria Age greater than 40 years History of urologic disorder or disease History of irritative voiding symptoms History of urinary tract infection Analgesic abuse ( Phenacetin) History of pelvic irradiation.
Haematuria Patients Work Up History • Age • Residency. • Occupation • Duration. Episodes, Urine color darkness • Painless or painful • Timing of haematuria • Clots and shape of clots • Trauma • Bleeding from other sites • Associated Symptoms urinary and Systemic • History of :Bleeding disorders, SC, TB, Bilharzias & stone disease. • Family History of : Malignancy, hematological disorders, renal diseases • Drugs • Colored food or drinks intake. • Menses, Exercise, Sexual intercourse ( Transient Microscopic). • Smoking
Asymptomatic microscopic haematuria in children does not mandate aggressive evaluation other than long-term follow-up, whereas it is important to evaluate asymptomatic gross haematuria
For young women with microscopic haematuria, symptoms and urinary finding of UTI just do: Urine culture Treat UTI Repeat MSU 6 weeks after treatment No need for further work up
Urologic Evaluation of Asymptomatic Microscopic Haematuria Follow up by Measuring BP. MSU. Urine Cytology. U & E.
Lap Investigations • MSU • Urine Culture ( Pyogenic Organisms). • Urine FOR AFB ( Tuberculosis). • Urine Cytology and Tumor markers • CBC & Hematology • U&E • LFT
When to refer to urologist: If there is a positive findings, that requires urological intervention If the patient is high risk for GU neoplasm, with no findings in the lap and radiology work up.