Hematuria & obstructive Uropathy

Hematuria

Physical Examination of Urine

an evaluation of color, turbidity, specific gravity and osmolality, and pH.

Red HematuriaHemoglobinuria/myoglobinuriaAnthrocyanin in beets and blackberriesChronic lead and mercury poisoningPhenolphthalein (in bowel evacuants)Phenothiazines (e.g., Compazine)Rifampin

Urinary dipstick

Most common screening test for hematuria

The reagent strip that detects blood utilizes hydrogen peroxide, which catalyzes a chemical reaction between hemoglobin (or myoglobin) and the chromogen tetramethylbenzidine

Different shades of blue-green are produced according to the concentration of hemoglobin in the urine

Centrifuged urine

Centrifuged urine

• In hemoglobinuria, the supernatant will be pink. This is because free hemoglobin in the serum binds to haptoglobin, which is water insoluble and has a high molecular weight. This complex remains in the serum, causing a pink color. Free hemoglobin will appear in the urine only when all of the haptoglobin-binding sites have been saturated.

Centrifuged urine

• In myoglobinuria, the myoglobin released from muscle is of low molecular weight and water soluble. It does not bind to haptoglobin and is therefore excreted immediately into the urine. Therefore, in myoglobinuria the serum remains clear.

Quantity of Hematuria

• Microscopic Hematuria : seen only under microscope

• Gross Hematuria : visible, urine is pink, cola, red

• 5 times the number of life-threatening conditions when compared with patients with microscopic hematuria.

How to evaluate hematuria?

By asking question• 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?

Timing of Hematuria

Frequently indicating the site of origin asInitial hematuria

from urethra, least common, usually secondary to inflammation

Terminal hematuriasecondary to inflammation at bladder neck or

prostatic urethra

Total hematuriafrom bladder or upper tract, most common

Total Hematuria

Initial Hematuria

Terminal Hematuria

Pain•Painful hematuria▫Painful micturition

▫ inflammation of the bladder or prostate.

▫Colicky groin pain ▫ ureteral calculus.

▫Burning pain in the penis or urethral opening in women ▫ urinary infection.

▫Pain in the perineum associated with dysuria, fever, and rigors ▫ seen in prostatitis.

▫Constant dull flank pain▫ sign of advanced RCC

Classification : Pain

• Painless (Gross) Hematuria• With Age > 50 years ( Mostly Men ) is HALLMARK for

bladder cancer.

Clots

• The presence of clots usually indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.

Shape of Clots

Amorphous clots : bladder or prostatic urethral origin

Vermiform (wormlike) clots, particularly if associated with flank pain : the upper urinary tract : ureter

Duration of Hematuria

• Transient Hematuria• Benign & without any obvious etiology in 39%of young adults • 8-9% of adults >50y/o – malignancy

• Persistent Hematuria• Defined as three positive urinalyses, based on a test strip and microscopic

examination, over a 2- to 3- week period• Microscopic – 5% malignancy• Macroscopic – 20% malignancy

Causes of Hematuria

• Congenital/inherited• PCKD, Hematologic abnormalities

• Trauma• Neoplasm

• Benign or malignant

• Infection/Inflammation• Metabolic

• Stone

• Miscellaneous• Drug

Most common cause of hematuria 0-20 YR ACUTE GLOMERULONEPHRITIS

ACUTE UTICONGENITAL UT ANOMALIES WITH OBSTRUCTION

20-40 YR ACUTE UTISTONESBLADDER TUMORS

40-60 YR (MEN) BLADDER TUMORSACUTE UTISTONES

40-60 YR (WOMEN) ACUTE UTISTONESBLADDER TUMORS

60 YR (MEN) BPHBLADDER TUMORSACUTE UTI

60 YR (WOMEN) BLADDER TUMORACUTE UTI

Hematuria

Nephrologic proteinuria

Glomerular

Dysmorphic

Erythrocytes

Erythrocyte casts

Tubulointerstiti

alCircular

Erythrocytes

UrologicCircular Erythrocytes

Glomerular Hematuria

•Begin with a thorough history▫IgA nephropathy (Berger's disease) ▫Familial nephritis or Alport's syndrome▫Goodpasture's syndrome▫Systemic Lupus erythematosus▫Poststreptococcal glomerulonephritis

Non-glomerular Hematuria

– Non-glomerular hematuria or essential hematuria includes primarily urologic rather than nephrologic diseases

– Common causes of essential hematuria include urologic tumors, stones, and UTIs

Non-glomerular Hematuria

• Characterized by circular erythrocytes and the absence of erythrocyte casts

An algorithm for the evaluation of nonglomerular hematuria

History

+ Family History of bleeding disorder or bleeding tendency• Abnormal

coagulation studies• Hemophilia• Thrombocyto

penia• Thrombotic

Thrombocytopenia purpura

• Disseminated Intravascular coagulopathy

Serum and 24- hour urine calcium and uric acid• Familial

urolithiasis

+Family History of renal cystic disease• IVU, Renal

ultrasonography• Medullary

sponge kidney• Polycystic

kidney disease

Systemic anticoagulation• PT,PTT with

therapeutic range• IVU renal

Ultrasonography• R/O

urologic abnormality

• PT,PTT above therapeutic range• Stop

coagulant• Consider

IVU Renal ultrasonography

Work –up : Laboratory StudiesUrinalysisPhase contrast microscopyBUN/serum creatinine: Elevated levels of BUN and creatinine

suggest significant renal disease as the cause of hematuriaHematologic and coagulation studies: CBC counts , Platelet

countsUrine calcium : A calcium excretion of more than 4 mg/kg/d

or a urine calcium-creatinine ratio of more than 0.21 are considered abnormal.

Serologic testingUrine culture : A midstream or clean-catch specimen of urine

should be obtained for culture sensitivity whenever a urinary tract infection is suspected.

Work-up : Imaging Studies

•Renal and bladder ultrasonography▫ Urinary tract anomalies, such as hydronephrosis,

hydroureter, nephrocalcinosis, tumor, and urolithiasis, are readily revealed with ultrasonography

▫Compared with other imaging studies, sonography is rapid, noninvasive, readily available, and devoid of exposure to radiation

▫In individuals with severe obesity, a more accurate definition of renal structures and surrounding organs can be achieved using only CT scanning

Work-up : Imaging Studies

•Other imaging studies ▫A spiral CT scan is particularly useful in the

detection of urolithiasis, Wilms tumor, and polycystic kidney disease

▫Voiding cystourethrograms are valuable in detecting urethral and bladder abnormalities that may result in hematuria (eg, cystitis)

▫Radionuclide studies can be helpful in the evaluation of obstructing calculi

Microscopy of urinary sediment. Typical appearance in non-glomerular hematuria: RBCs are uniform in size and shape but show two populations of cells because a small number have lost their hemoglobin pigment

Microscopy of urinary sediment. A cast containing numerous erythrocytes, indicating glomerulonephritis

Advantages Disadvantagesr

IVP Excellent for kidney and ureter

May miss bladder lesion

Cystoscopy Best for bladder Invasive and expensive

Ultrasonogram Excellent for kidney Less sensitive for ureter and bladder

Retrograde pyelogram Best for ureter Invasive

CT The best to examine renal parenchyma

Expensive

Persistent microscopic Hematuria

Evidence of glomerular disease

Renal parenchymal disease evaluation Urologic evaluation

Renal Biopsy Risk of urologic malignancy- Age > 40 years- Heavy smoking- Pelvic radiation- Exposure: dyes benzene- Chronic urological tract

infection

Yes

Yes

No

No

- Urine 24-hr, calcium- Imaging- Cystoscopy + Cytology

- Imaging- Cystoscopy + Cytology

Obstructive Uropathy

Definition

• Functional or anatomic obstruction ofurinary flow at any level of the urinarytract

Classification

Obstructive uropathy may be classified in to- congenital/acquired- Benign/malignant- Partial/complete- Unilateral/bilateral- Acute/Chronic

Etiology

Congenital• meatal stenosis• ureteral strictures• posterior urethral strictures• ureterovesical junction

obstruction ureteropelvic junction

obstruction (various causes)• neurologic deficites

Acquired• urethral strictures

inflammatory or traumatic• bladder outlet obstruction• vesical tumor• neurogenic bladder• extrinsic ureteral

compression• ureteral or pelvic stones,

strictures and tumor

History taking: Present Illness

A. Symptoms

1. Lower urinary tract (urethra and bladder)-hesitancy-lessened force and size of the stream-terminal dribbling

History taking: Present Illness

2.Upper urinary tract ( ureter and kidney)-pain in the flank radiating along the course of the ureter-gross hematuria (from stone)-GI symptoms-fever with chills- may be asymptomatic

Physical Exam: Present Illness

B. Signs1. Lower urinary tract

-Palpation of urethra-Vesical distention

Physical Exam: Present Illness

2. Upper urinary tract-Palpation of kidney

Pathogenesis (pathophysiology)

The changes in the various segments in the urinary tract, depending on the obstructive severity and duration

1. Urethral changes: dilatation, diverticulum

2. Bladder changes: trabeculation , trigone hypertrophy , diverticulum

• 3. Ureteral changes: distention, dilatation and hydroureter

4. Pelvicalyceal changes: first shows evidence of hyperactivity and hypertrophy and then progressive dilatation and followed by flattening of the papillae and finally clubbing of the minor calyces.

5. Renal Parenchymal Changes : compression, ischemic atrophy.

Clinical findings

1.Symptoms and signs: infravesical obstruction :difficulty of

voiding,weak stream ,diminished flow rate,terminal dribbling,burning ,frequency.

Supravesical obstruction :renal pain or renal colic,if gradually--asymptomatic or enlarged kidney

Clinical findings

2.Laboratory findings•Urinalysis•BUN •Creatinine•Impaired kidney function elevated blood urea nitrogen and serum creatinine

Clinical findings3.X-Ray findings , IVP, Cystoscopy , Retrograde

pyelography• localizing the site of obstruction• demonstrate the extent of the obstructed

segment• anatomic changes • functional changes

Clinical findings

4.Special Examination Instrumental calibration of sites of obstruction

is also valuable• radioisotope renography• ultrasonic examination shows hydronephrosis

and residual urine • Urine flow rate• CT

Treatment

• 1. Relief of obstruction-BPH or obstructing bladder tumors require surgical removal -impacted stones must be removed

Treatment

2.urethral stricture can be dilatated or urethrotomy or urethroplasty

Treatment

3.Percutaneous nephrostomy or double –J stent4.GFR< 10% : nephrectomy

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