Haematuria Prof. Mohamed Sobh

Urology & Nephrology Center, Mansoura University, Egypt

HAEMATURIA

ByMohamad A. Sobh, MD, FACP

Prof. of NephrologyUrology & Nephrology Center

Mansoura UniversityEgypt


Definitions:Normally the number of RBCs in urine

should not be more than 5 RBCs/ high power field on microscopic examination of fresh centrifuged urine sample.

So, haematuria is defined as a secretion of more than 5 RBCs/ HPF in urine.

Haematuria


Transient microscopic haematuria is relatively common. Up to 40% of adults between ages of 18 and 33 may have microscopic haematuria at least once, and up to 16% may have it in two or more occasions.

Therefore, an extensive workup is not indicated except in high-risk patients, > 50 years of age and those patients with other clinical or urinary abnormalities.


Initial is usually urethral.Terminal hematuria is usually prostatic or bladder origen.Total hematuria is either bladder, ureteral or renal origen.Gross or Microscopic.Painfull or painless.Symptomatic or Asymptomatic.

Patterns Of Haematuria


Transient haematuria •Exercise ( ‘ joggers ’ nephritis ’ ).

•Menstruation.. •Viral illnesses.

•Trauma


In gross hematuria, urine looks red if alkaline, but brown or coca-cola like if urine is acidic due to denaturation of the hemoglobin.


False positive test for haematuria:

Haemoglobinuria.

Myoglobinuria.

Ascorbic acid.

False negative test for hematuria:

Highly diluted urine.


Differential Diagnosis of Haematuria:A- First, haematuria should be differentiated from other causes of red or brownish urine:

Haemoglobinuria (haemolysis) Myoglobinuria (muscle damage) Porphyrins (in porphyria) Bile (in jaundice) Melanin (in melanoma) Alkaptonuria, Food dyes. Drugs as PAS or phenylphthalein.


Dipsticks (Hemastix) will be positive with haematuria, haemoglobinuria and with myoglobinuria but negative with other causes e.g. porphyrins bile melanin, alkaptonuria, food dyes and drugs as PAS or phenylphthalein.

Microscopy will show RBC’s only with haematuria.


B-Haematuria could be glomerular (because of glomerular disease, sometimes called medical); or non glomerular (sometimes called surgical).

Glomerular haematuria could be differentiated from non glomerular haematuria by:

1. The shape of RBCs in urine are small and dysmorphic in cases with glomerular haematuria while it will be normal in case of non glomerular haematuria.


2. Proteinuria is present in most cases of glomerular hematuria but not in cases of non glomerular hematuria.

3. Casts, especially red cell casts are seen in glomerular haematuria.

4. Blood clots indicate non-glomerular bleeding and can be associated with pain & colic.


(in dipsticks test reaction occurs between orthotolidine and haemoglobin or myoglobin).


Causes of Haematuria I. Haematuria of renal origin:

Glomerular haematuria Renal infection and tubulointerstitial diseases. Renal neoplastic diseases: Hereditary renal diseases Coagulation defect Stone disease. Renal vascular disease Exertional haematuria.

II. Haematuria of ureteral origin: III. Haematuria of bladder origin: IV. Haematuria of urethral origin.


Haematuria of renal origin: a.Glomerular haematuria: Either primary glomerular disease (e.g. IgA nephropathy, mesangial proliferative glomerulonephritis or crescentic glomerulonephritis); or secondary glomerulonephritis i.e. renal involvement is a part of systemic disease (e.g.post-strephococcal glomerulonephritis, Henoch-Schönlein purpura, SLE, polyarteritis nodosa).


b.Renal infection and tubulointerstitial diseases: Pyelonephritis, renal papillary necrosis, tuberculosis, and toxic nephropathies.

c.Stone disease.d.Renal neoplastic diseases: Renal cell

carcinoma, transitional cell carcinoma of the renal pelvis and others.

e.Hereditary renal diseases: Medularly, sponge kidney, polycystic kidney disease, Alport’s syndrome, and thin basement membrane disease.


f. Coagulation defect: use of anticoagulant, liver disease and thrombocytopaenia.

g. Renal vascular disease: Renal infarction, renal vein thrombosis or malignant hypertension.

h. Exertional haematuria.


II. Haematuria of ureteral origin: a. Malignancy.b. Nephrolithiasis.c. Ureteral inflammatory condition

secondary to nearby inflammation e.g. diverticulitis, appendicitis or salpingitis.

d. Ureteral trauma e.g. during ureteroscopy.

e. Ureteral varices, aneurysms, or arteriovenous malformation.


III. Haematuria of bladder origin: a. Infection: schistosoma, viral or bacterial

cystitis.b. Neoplasma.c. Foreign body in the bladder e.g.

stones.d. Trauma: During instrumentation or

accidental.e. Drug: e.g. cyclophosphamide induced

haemorrhagic cystitis.


Cyclical haematuria in ♀ suggests endometriosis of the urinary tract


IV. Hematuria of urethral (or associated structures) origen:

a. Urethritis, foreign body or local trauma to the urethra.

b. Prostate: Acute prostatitis, benign prostatic hypertrophy.


1. First exclude haemoglobinuria and myoglobinuria since both of them can also cause positive dipstick test for haematuria. This is done by microscopic examination of fresh urine sample. In case of haematuria, RBCs could be seen while in the other two conditions no RBC’s could be seen.

Investigations of a case of haematuria


In case of myoglobinuria, clinical examination may show manifestations of muscle disease and the examination of urine by immunoelectrophoresis may show myoglobin.

In case of haemoglobinuria, manifestations of haemolysis may be evident


2. Examination of urine for: Proteinuria.

Casts.

Pus.

Bacteria (specific and non specific)

Culture (Ordinary and special)

PCR (TB-DNA)


3. Ultasound, plain X-ray, I.V.P. (if

serum creatinine is normal), and

possibly angiography, for the

diagnosis of surgical diseases e.g.

stone, malignancy, infection, or

malformations.


4. RBCs in urine could be examined for its shape to differentiate glomerular (small, distorted) from non glomerular causes (by phase contrast microscopy).

5. Kidney function tests.6. Specific investigations for diagnosis of

systemic disease causing haematuria e.g. SLE.

7. Kidney biopsy for glomerular haematuria.


Microscopic haematuria and the risk of ESRD• A recent longitudinal study of 1.2 million young individuals (aged

16 – 25) presenting for military service found an initial 0.3% prevalence of persistent microscopic haematuria (with normal SCr and proteinuria <200mg/day).

• Males were affected twice as commonly as females.• During 21 years ’ follow-up, ESRD developed in 0.7% of those with (and

0.045% of those without) initial microscopic haematuria.• This gave an adjusted hazard ratio of 18.5.• The mean age of ESRD treatment was earlier (34 vs 38) in the haematuria

cohort and attributed mainly to glomerular disease.• While the relevant advisory bodies do not presently advocate population

screening, these recent data have led to a call for selected screening of younger patients so that they can be followed up more closely for the development of overt renal disease.

* Vivante A, Afek A, Frenkel-Nir Y, et al . (2011). Persistent asymptomatic isolated microscopic hematuria in adolescents and young adults and risk for end-stage renal disease. JAMA .


1. Treatment of the cause.2. Haemostatic e.g.:

Cyclokapron. Vitamin K DDAVP Frish frozen plasma.

3. Haematenics and blood transfusion.

Treatment Of Haematuria

Haematuria Prof. Mohamed Sobh

Health & Medicine

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