Haematuria
Miguel Cabalag
Red Urine
©2011 UpToDate®
Definition
• Macroscopic (gross)
– Red – brown urine
• Microscopic
– ≥3 RBC per high-power field on microscopic
evalation of urinary sediment.
Glomerular vs Extra-glomerular
Glomerular
Extra-Glomerular
Colour
Red/smoky brown/Coke
Red/Pink
Clots
Absent
May be present
Proteinuria
<500 mg/d
May be >500 mg/d
RBC casts
Present
Absent
RBC morphology
Dysmorphic
Normal
Adapted from ©2011 UpToDate®
Anatomy
DDx
©2010 UpToDate®
DDx (Macroscopic)
• MINTSIC
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Medical (GN, AF)
Infection (acute – UTI; chronic – TB, schistosomiasis)
Neoplasm (benign, malignant, PCKD)
Trauma
Stones
Iatrogenic (previous urological surgery)
Coagulopathy
• Excessive exercise
• Transient unexplained
DDx (Microscopic)
• Glomerulonephritis
– IgA Nephropathy
– Post-streptococcal GN
– Thin Basement membrane Disease
– Membrano-proliferative GN
Hx
• Characteristics:
– Colour, ?clots, timing
(intermittent/terminal/start/independent), duration, etc
• Infection: f/c/r, Irritative sx - frequency, urgency, nocturia,
dysuria, incontinence (urge), flank/suprapubic/penile pain,
sexual hx, urethral dc
• Stones: renal colic
• Prostate: Obstructive Sx
• Malignancy: ?Painless, LOW, LOA, night sweats,
smoking/ETOH/exposure to industrial
dyes/cyclophosphamide (Bladder Ca)
• Hx of trauma
• Coagulopathy: easy bruising, bleeding elsewhere, FHx,
prev dental procedures
Hx ctd
• GN: Recent URTI/sore throat (post infx GN/IgA
nephropathy), haemoptysis/SOBOE (Goodpasture’s,
Wegener’s granulomatosis), frothy urine (proteinuria),
SOA
• Medications (warfarin, cyclophosphamide, rifampicin,
chemoTx)
• Recent urological surgery
• PHx: T2DM, AF, Sickle Cell anaemia
• FHx of renal disease (PCKD)
• Exclude other sources: ?period,
?malaena/haematochezia
O/E
• General: well/unwell, restless (colic), anaemia
• Obs: haemodynamically stable, ?febrile
• Abdo: peritonism, organomegaly, pain on
ballotment of kidneys, flank pain, LA
• Genito-urinary: ?urethral discharge, period
• DRE: prostate, (? GIT source)
• Resp: consolidation (?pneumonia)
• CVS: AF, stigmata of Infx Endocarditis
• Urinalysis: blood, leuc, nitrites, protein, glucose
Ix
• Bloods:
– FBE + film, UEC, CMP, Uric Acid, PSA, LFTs (ALP), Glucose, CRP,
ESR, Coags
• Urine:
– MCS (glom vs non-glom), Cytology, PCR (gonorrhoea/chlamydia)
• Imaging:
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CT-KUB (non contrast – stones)
CT-IVP (filling defect – malignancy)
Renal tract USS
XR-KUB
• Cystoscopy
Case 1
• 65 yo male p/w 3/52 history of red coloured
urine. Intermittent, painless, present throughout
stream. No obstructive/irritative sx. Otherwise
well.
• PHx: Nil significant
• Meds: Glucosamine, Cholecalciferol
• Smoker (50 pk yrs)
• ETOH (2 stubbies/d)
– DDx?
DDx
• MALIGNANCY!
– Renal Cell Ca
– Bladder TCC
• GN
Ix?
Ix
• Bloods: FBE, UEC, CMP, LFT (ALP)
• Urine: MCS, Cytology
• Imaging:
– Flex Cystoscopy
– CT-IVP
• Staging (TNM) – Lung, liver, bone
– CT-Abdo/Pelvis
– CXR
– Bone scan
Staging
Rx
• Stage 1 (Ta/T1): TURBT +/- intravesical therapy (BCG)
• Stage 2 (>T2) (muscle invasive disease): Neoadjuvant
chemotherapy + Radical cystectomy with urinary
diversion (ileal conduit)
– Bladder sparing: Complete TURBT + RT + Chemo
• Chemotherapy:
– Methotrexate, vinblastine, doxorubicin, cisplatin (MVAC)
– Gemcitabine + cisplatin (GC)
• TCC: Long term surveillance (Field effect)
Take home message
• Painless haematuria in >40 yo = malignancy
until proven otherwise
Case 2
• 30 yo male, p/w red coloured urine a/w
abdominal pain.
• Further hx?
Case 2
• HOPC: Severe 10/10 L flank pain radiating
down to groin, intermittent. Truck driver (high
protein, low fluid intake)
• PHx: HTN, Obesity, Gout, T2DM
• Meds: Thiazide, Allopurinol, Metformin,
Aspirin
• Smoker (40 pk yrs)
• ETOH (4 glasses of red wine/d)
• FHx of nephrolithiasis
Common sites: (PUJ, VUJ, pelvic brim)
Case 2
• Ix:
– Bloods: FBE, UEC, CRP, CMP, Uric Acid
– Urine: FWT, MCS
– Imaging:
• Non-contrast CT-KUB
Mx
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When to refer to Urology:
– >5 mm/Staghorn/stone doesn’t pass/infection +
obstruction/urosepsis/ARF/Solitary kidney/Bilateral obstruction
Analgesia
– Paracetamol, NSAIDs (Indomethacin Suppository), Opioids (oral/SC/IV)
Anti-emetics
IVF
Medical therapy: CCB (Nifedipine), alpha blockers (Tamsulosin)
Surgical:
– Extracorporeal Shock Wave Lithotripsy (ESWL)*/Ureterscopic
lithotripsy/Percutaneous nephrolithotomy
Send stone for analysis
Dietary modifications (inc fluid intake)
Urine modification:
– Ca stones: Thiazide diuretic and low Na diet
– Uric Acid stones: Allopurinol
– Cystine stones: Alkalinization of urine (Ural – NaHCO3/Potassium Citrate)
Mx
• Stone radiopauqe?
– No  Probable uric acid stone
• Fluids + Analgesia; Alkalinize urine w Potassium Citrate
– Yes  Fluids + Analgesia  stone >5mm?
• Yes  Refer to Urology
– Staghorn Calculus  Percutaneous lithotomy + ESWL
– Calyceal/Upper ureteral calculus ESWL
– Distal ureteral calculus  Ureteroscopy/ESWL
• No  Strain urine and continue hydration + analgesia.
Await stone to pass
– Renal Tract USS in 2/52 if hydronephrosis/multiple stones on
initial evaulation
Nephrolithiasis
• Composition:
– 80%: Ca stones:
• Ca oxalate
• CaPO4
– Uric Acid (RADIOLUCENT)
– Struvite (Mg, Ammonium, PO4)
– Cystine
Questions?