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HAEMATURIA

Common finding
Incidental

DEFINING HAEMATURIA Visible haematuria Non visible haematuria (dipstick and microscopic)

Indication for urine dipstik testing


Lower urinary tract symptoms Upper urinary tract symptoms Diagnosis of hypertension Diabetes(at least annually) Newly detected renal dysfunction(e GFR<60ml/min) Suspected multisystem disease with possible renal

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

and if simple doesn't require further investigations.


Presence of bacterial peroxidases can cause a false

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

Polycystic kidney disease


Haemolytic uremic

Good pastures

syndrome Alports syndrome

syndrome Acute pyelonephritis

Causes of haematuria
UROLOGICAL
Malignancy Benign tumour Trauma Calculus PKD Renal vasculature problems Renal toxins SLE

GENERALIZED

Medullary sponge kidney

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

Signs of infective endocarditis, murmur


Cardiovascular Lung signs (rare) Respiratory Palpable masses, distended bladder

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

Full blood count ESR/PV U&Es

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

Kidney ,Ureter and Bladder X-ray Ultrasound scan

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,

eGFR and ACR/PCR Re referral to urology if;


Significant or increasing proteinuria(ACR>30 or

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.

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