Medical Discussion

Hematuria

`Remember:`

Normal urine contains < 3 RBCs/HPF
Microscopic hematuria = > 3 RBC/HPF in urine.
Positive Dipstick for blood in urine indicates:
1. Hematuria
2. Haemoglobinuria
3. Myoglobinuria
M/C cause of hematuria is Acute Cystitis^Q.
M/C cause of glomerular hematuria is IgA Nephropathy^Q.
Papillary necrosisis is the cause of hematuria in Diabetics, Sickle cell disease, analgesic abuse, African Americans.
M/C cause of milky/Cloudy urine is – Phosphaturia^Q.
M/C cause of painless hematuria after age of 50 yrs is – Bladder Cancer^Q
Pseudohematuria = Seen in ingestion of rifampicin, beet root, phenolpthaline.

`Causes of Renal Papillary Necrosis`

Diabetes mellitus
Pyelonephritis
Urinary tract obstruction
Analgesic abuse
Sickle cell hemoglobinopathies
Renal transplant rejection
Cirrhosis of the liver
Dehydration, hypoxia, and jaundice of infants
Miscellaneous: Renal vein thrombosis, cryoglobulinemia, renal candidiasis, contrast media injection, amyloidosis, calyceal arteritis, necrotizing angiitis, rapidly progressive glomerulonephritis, hypotensive shock, acute pancreatitis

N.B.: Papillary Necrosis is not found in Renal Cell Carcinoma^Q.

`Differential Diagnosis of Coloured Urine`

Cloudy/milky

Phosphaturia (m/c)
Pyuria
Chyluria

Red

Hematuria
Hemoglobinuria/myoglobinuria
Anthocyanin in beets and blackberries
Chronic lead and mercury poisoning
Phenolphthalein
Phenothiazines
Rifampin

Orange

Dehydration
Phenazopyridine (Pyridium)
SulfasalazinE

Yellow

Normal
Phenacetin
Riboflavin
Bilirubin

Green-blue

Biliverdin
Indicanuria (tryptophan indole metabolites)
Amitriptyline
Indigo carmine
Methylene blue
IV promethazine (Phenergan)
Resorcinol
Triamterene (Dyrenium)

Brown

Urobilinogen
Porphyria
Aloe, fava beans, and rhubarb
Chloroquine and primaquine
Furazolidone (Furoxone)
Metronidazole (Flagyl)
Nitrofurantoin (Furadantin)
Brown-black Alcaptonuria (homogentisic acid)
Hemorrhage
Melanin
Tyrosinosis (hydroxyphenylpyruvic acid)
Cascara, senna (laxatives)
Methocarbamol (Robaxin)
Methyldopa (Aldomet)
Sorbitol

`Frequently Asked Questions:`

Etiology of hematuria.
Differential diagnosis of hematuria.
What is microscopic hematuria?
Short notes : painless hematuria.
Discuss the causes, investigations and management of a case of hematuria.
A male patient aged 60 years attended surgical OPD with painless hematuria. How will you diagnose and treat the case?

`Etiology:`

Glomerular Hematuria ( = dysmorphic RBCs, RBC cast, and proteinuria)
1. IgA nephropathy (Berger disease)
2. Mesangioproliferative GN
3. Focal segmental proliferative GN
4. Familial nephritis (e.g., Alport syndrome)
5. Membranous GN
6. Mesangiocapillary GN
7. Focal segmental sclerosis
8. Unclassifiable
9. Systemic lupus erythematosus
10. Postinfectious GN
11. Subacute bacterial endocarditis.
Non – Glomerular Hematuria ( = circular RBC, no cast, proteinuria)
- Medical
  - Tubulointerstitial disease
  - Renovascular
  - Systemic
  - Drugs : Analgesics
  - Anticoagulants
  - Blood Dyscrasia
  - Papillary necrosis
  - Medullary Sponge Kidney
  - PCKD
- Surgical
  - Stone Disease
  - UTI
  - Urologic Tumors
  - BPH
  - CA Prostate
  - Trauma

`Memoranda:`

Essential hematuria = Circular RBC, No Cast, No proteinuria
Exercise induced hematuria:
- Occurs in long distance runners (>10kms)
- Noted at end of the run.
- Disappears with rest.
Origin
- Renal – IgA nephropathy.
- Bladder – Bladder tumor.

`Approach:`

In evaluating hematuria, following questions should be asked, and which help the subsequent diagnostic evaluation efficiently:

Is the hematuria gross or microscopic?
At what time during urination does the hematuria occur (beginning or end of stream or during entire stream)?
Is the hematuria associated with pain?
Is the patient passing clots?
If the patient is passing clots, do the clots have a specific shape?

History

H/O Trauma, drug intake.
Timing:
- Initial hematuria
  - from the urethra;
  - least common,
  - secondary to inflammation.
- Total hematuria
  - most common
  - from the bladder or upper urinary tracts
- Terminal hematuria
  - secondary to inflammation in the bladder neck and prostatic urethra.
  - Why terminal?
    - Because the bladder neck contracts,squeezing out the last amount of urine.
H/O LUTS (hesitancy, urgency, frequency, nocturia, poor stream – indicate BOO/Prostatomegaly)
H/O associated pain
- With pain
  - Stone
  - Trauma
- without pain
  - Tumor
N.B. Hematuria, is usually not painful unless it is associated with inflammation or obstruction.
H/O Gross/microscopic hematuria.
H/O passage of clots
- Presence of Clots indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.
- Shape of Clots
  - Amorphous clots
    - Origin: Bladder or prostatic urethra
  - Vermiform(wormlike) clots
    - Origin: Upper tract ( kidney & ureter )

General survey

Vitals: Pallor / BP / RR / HR / Temp / Urine output

Abdominal examination:

Renal lump
Palpable bladder
Renal angle tenderness (Infective origin)
Any bruise in the flank after trauma.
DRE
- Evaluate prostatic condition.

Investigations

Urinalysis
- pH (normal pH = 5.5 – 6.5):
  - if alkaline indicates infection
  - sterile pyuria in acidic urine^Q
    - Causes are TB, Stone, Malignancy, Interstitial nephritis, ↑IL-6 and IL-8.
- Culture: To detect uro-pathogens.
USG of KUB Region:
- Mainly to detect any
  - Mass
  - Hydronephrosis
  - Prostatic volume
  - Post void residual
  - Any stone disease
Cystoscopy:
- Cystoscopy should be performed as soon as possible, because frequently the source of bleeding can be readily identified.
- All patients with hematuria, except young women (<40 years) with acute bacterial hemorrhagic cystitis, should undergo urologic evaluation.
- Older women and men who present with hematuria and irritative voiding symptoms may have cystitis secondary to infection arising in a necrotic bladder tumor or, more commonly, flat carcinoma in situ of the bladder.

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Dr. Debasis Maity