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Common finding
Incidental
DEFINING HAEMATURIA Visible haematuria Non visible haematuria (dipstick and microscopic)
involvement.
Innocent haematuria
Haemoglobinuria Myoglobinuria Menstruation Sexual intercourse Acute intermittent porphyria Food :beet root, black berries, rhubarb Drugs: nitrofurantoin,senna,rifampicin,phenolphthalein,chlo roquine,doxorubicin Chronic lead or mercury poisoning
HAEMATURIA
UTI typically causes non visible transient haematuria
positive dipstick test Dipstick testing for blood is less sensitive in the urine with high specific gravity and heavy proteinuria
CAUSES OF HAEMATURIA
PRE RENAL CAUSES
Bleeding diathesis Purpura
Atrial fibrillation
Infective endocarditis Scurvy
Leukaemia
Thrombocytopenia haemophilia
CAUSES OF HAEMATURIA
RENAL CAUSES
NEPHROLOGICAL
IgA nephropathy
Glomerulonephritis Polyarteritis nodosa
Good pastures
Causes of haematuria
UROLOGICAL
Malignancy Benign tumour Trauma Calculus PKD Renal vasculature problems Renal toxins SLE
GENERALIZED
CAUSES OF HEMATURIA
POST RENAL CAUSES
URETERIC
Calculus Carcinoma
BLADDER/PROSTATIC
Tumour BPH Prostatic cancer Calculus Cystitis Injury/FB Purpura Schistosomiasis
Papilloma
schistosomiasis
CAUSES OF HAEMATURIA
URETHRAL
Acute urethritis Calculus Injury Carcinoma Papilloma Urethral meatal ulcer F.B
Approach to haematuria
Thorough history including Urinary symptoms Recent history (trauma/muscle injury/causes of
factitious haematuria/exercise/foreign travel) Systemic features (fever, weight loss) other symptoms(bleeding,bruising) Co-morbidity Drug history Occupation Family history
EXAMINATION
Anaemia , wt. loss , skin colour, bruising/bleeding General Pulse rate, blood pressure, temp. Vital signs
Abdominal
Prostatic enlargement-BPH/cancer Rectal examination
INVESTIGATING HAEMATURIA
Urine MCS Urine albumin:creatinine ratio To exclude UTI .Red cell cast indicates glomerulonephritis Perform if proteinuria on dipstick of 1+ or more. 24 hrs protein collection is rarely necessary Anaemia, signs of infection, thrombocytopenia Raised in infection or malignancy For renal function and eGFR
INVESTIGATING HAEMATURIA
Clotting screen Remember that haematuria in those on anti coagulants can occur with normal clotting screen Not in context of UTI that may give a false high reading. Measure 4-6 weeks later. To look for stones To look for abnormalities of the renal tract and the kidneys. USS is as sensitive to hydronephrosis and renal masses as IVU and is more cost effective.
PSA
REFERRAL CRITERIA
URGENT (2 WEEKS WAIT) REFERRAL (urology)
Visible haematuria (unless GN is suspected) Haematuria with recurrent or persistent UTI in adult
over 40 years Persistent non visible haematuria in adult over 50 years. Abdominal mass identified clinically or on imaging that is thought to arise from urinary tract.
REFERRAL CRITERIA
UROLOGY
All patient with symptomatic non-visible haematuria
who don't meet the criteria for urgent referral. Patient with persistent asymptomatic non-visible haematuria age 40-50 years.
REFERRAL CRITERIA
NEPHROLOGY
Evidence of decline of eGFR (by >10ml/min in previous 5
years or by >5ml/min in the last year). Stage 4 or 5 kidney disease. Significant proteinuria (ACR 30 or more or PCR 50 or more). Isolated haematuria with hypertension in those under 40 years. Visible haematuria coinciding with intercurrent ,usually upper respiratory, infection.
If no cause established
Annual assessment(while haematuria persists)of BP,
PCR>50) Estimated GFR <30ml/min(Confirmed on at least 2 readings and without an identifiable reversible cause) Deteriorating eGFR(>5ml/min in 1 year or>10ml/min in 5 years.