HAEMATURIA

The presence of blood or red blood cells in urine.

Haematuria may be the only indication of pathology in the urinary tract and should not be ignored if noticed

Classification
Hematuria can be classified according to
Quantity Pattern Pain Frequency

Quantity
Macroscopic (Gross) here the amount of red blood cells is enough to discolour the urine. Gross hematuria can vary widely in appearance from light pink to dark red with clots. Patients with gross haematuria usually present with this as their primary complaint Microscopic This is detected microscopically (3-5 RBCs/HPF) or by dipstick testing. Patients do not present with microscopic hematuria as the primary complaint.

Pattern
Initial - describes blood presenting at the beginning of the urinary stream. It is usually produced by lesions of the prostate. Blood is produced by a problem within the prostate, accumulates within the lumen of the prostatic urethra, and is voided out first, followed by yellow urine from the bladder.

Terminal - describes blood presenting at the end of the urinary stream. It may result from lesions of the bladder, such as bladder stones and rarely bladder cancer.

 Frank/Total - describes bloody urine throughout the entire urinary stream. It is usually the result of lesions of the kidneys and ureters. Blood from the kidneys and ureters enters the bladder, mixes with the urine already in the bladder, turning it red. Bladder infections and bladder cancer are also common causes of total hematuria.

Pain
Painful usually associated with urinary tract infection.

Painless associated with bladder tumor, polycystic kidney disease

Frequency
Intermittent glomerular diseases, kidney stones, left renal vein hypertension, prostate hypertrophy

Continuous polycystic kidney disease, renal parenchymal disease (glomerulonephritis, IgA nephropathy)

 Blood of glomerular origin may be coca-cola coloured with dysmorphic RBCs and casts but blood from the lower urinary tract is usually bright red.

Aetiology
Non-urinary Tract Causes Sickle Cell Disease or trait Bleeding disorder Drugs (cyclophosphamide,, anticoagulants) Leukemia Systemic Lupus Erythematosus Neoplasm of adjacent organs Pelvic inflammatory disease Appendicitis Acute febrile illnesses Exercise Diabetes Mellitus Endometriosis

Aetiology - Lower Urinary Tract Causes

BLADDER Vesical Schistosomiasis Tumours Injury Cystitis Diverticula Calculi PROSTATE Benign Prostatic hyperplasia (BPH) Prostate carcinoma Acute or chronic prostatitis URETHRA Injury e.g. rupture, stones Acute gonococcal/non-gonococcal urethritis Posterior urethritis Urethral stricture Neoplastic e.g. transitional cell carcinoma Diagnostic procedures

Aetiology Upper Urinary Tract Causes

Congenital anomalies (e.g., ureterocele) Varices (renal pelvis, ureter) Genitourinary tuberculosis Infarction Infection -Acute or Chronic Glomerular nephritis Thrombosis/embolism/renal artery aneurysm Polycystic kidney disease Malignant hypertension Calculi Trauma Stones Hypercalcuria (present as dysuria, persistent or recurrent hematuria) Interstitial nephritis Tumours e.g. Wilms tumour Polycystic kidney disease Renal vein thrombosis Hydronephrosis Pyonephrosis Familial benign haematuria Hereditary nephritis (Alports syndrome)

Pseudohaematuria
Red discoloration has many other causes, which may mimic haematuria. These include:
Haemoglobin Pigments such as myoglobin, porphyrins, betanin (from beetroot), Rhodamine and food colouring. Drugs such as rifampicin, phenazopyridine, sulphonals, dindevan, trianol, and furadantin

Haemoglobin and myoglobin also produce a positive urine dipstick test and therefore only microscopy can prove true haematuria.

History
Demographics Age is probably the most important factor ALMOST ALL intermittent hematuria is benign in persons <50 years

History
HPC
When was it first noticed? Is it continuous or intermittent? Is it initial, total or terminal? Is this the first episode? Associated symptoms?- Dysuria? Abdominal pain? Fever? Night sweat? Weight loss? Rash? Joint pain? Fatigue? Oedema? Recent trauma? Strenuous exercise? Bleeding haemorrhoids and onset of menses to rule out artifactual haematuria

History
Past medical history
Any known renal, urinary, prostatic or bleeding disorders, hypertension, recent instrumentation, radiotherapy, chronic UTIs, Persistent irritative voiding symptoms

Drug history
Anticoagulant therapy, NSAIDS, Cyclophosphamide

Family history
hereditary nephritis, PKD, sickle cell disease.

Social history
smoking, industrial exposures (tetraethylchloride, benzene, aromatic amines) Recent travel Bathing in rivers.

Examination- General
Pallor indicates substantial blood loss Cachexia indicates malignancy Generalised/massive edema with hematuria may indicate fluid retention associated with renal failure or nephrotic syndrome Periorbital oedema may be the first physical sign of Nephritis. Look for signs of uremia e.g. uremic frost, pruritus, fishy breath, etc. Blood Pressure: hypertension may indicate Glomerulonephritis, Renal failure, Wilms tumor, polycystic kidney or renal vascular disease. The presence of petechiae, ecchymoses, lymphadenopathy, or splenomegaly may be indicative of a blood disorder or clotting disorder.

Examination Chest
The presence of a murmur suggests endocarditis or valvular heart disease which could cause renal embolism and infarction as possible causes of hematuria Crackles and rhonchi in goodpastures syndrome.

Examination - Abdomen
Palpable kidneys may point toward Wilms tumour in a male child or may be suggestive of hydronephrosis or polycystic kidney disease. An enlarged irregular liver suggests metastasis from a primary source elsewhere. An enlarged spleen may indicated Thrombocytopenic purpura, Leukemia or Sickle cell disease. Renal angle tenderness with hematuria points to pyelonephritis. The suprapubic region should be examined for urine retention, bladder or pelvic tumours. Suprapubic tenderness is commonly associated with bladder inflammation.

Examination Perineum
The external genitalia should be examined for blood at the external meatus, discharge, stricture, calculi, induration and fistula (stricture) A hyperemic, friable, doughnut-shaped mass at the site of urethral meatus is suggestive or a urethral prolapse. A digital rectal examination should be done to rule out prostatitis, BPH prostate carcinoma and bladder tumours. Tender, boggy prostate gland suggests prostatitis. A vaginal examination is indicated in females to rule out female genital tumours.

Investigations
Urinalysis
The urine is examined for red blood cells, granular casts, proteins, white blood cells, crystals, schistosoma ova and malignant cells.

Culture and Sensitivity of Urine

To identify the specific causative organism

FBC/CBC
should be done in all cases to determine the haemoglobin level most importantly, the white blood cell and platelet count.

 Sickling and G6PD status Kidney function test

Blood urea, nitrogen, creatinine and electrolytes.

Coagulation screen
Prothrombin time and Partial thromboplastin time

Investigations
Plain abdominal or pelvic X-ray It may reveal soft tissue swelling, calcification in vesical schistosomiasis, TB of the kidneys, osteophyte or osteoblastic bony metastasis and fractures of pelvis. Intravenous Urography (IVU) This may be indicated in renal tumours and renovascular abnormalities Retrograde ureteropyelogram- This is performed in all cases where an IVU shows non functioning kidneys, distortion of the renal calyces, Space occupying lesions, hydronephrosis and Ureteric obstruction.

Normal IVU

Retrograde ureterogram showing calculus in the pelvis

 Urethrocystogram In patients with urethral stricture, obstruction, calculi or rupture. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). These are invaluable in the diagnosis and staging of tumors. They are sensitive and detect cysts or tumors less than 2mm in size and all stones Ultrasonography Abdominal, pelvic ultrasound scans may reveal a tumor of the kidney, bladder and prostate.

CT scan showing renal ca of right kidney

Investigations
Radionuclide bone Scan helps in the diagnosis of bony metastasis. Cystoscopic examination It is more important in differential diagnoses of haematuria due to vesical schistosomiasis, Carcinoma in situ, carcinoma of

the bladder, BPH and prostate carcinomas.

Investigations
Biopsy Specimen of all tumours should be obtained for histology. It may be done by transrectal ultrasound guided biopsy or digitally directed per rectum for prostate carcinoma and by transurethral resection. Biopsies of bladder tumours can be obtained by Cystoscopy. Screen for gout in all cases of calculi

Treatment and Complications

Treatment
Treat underlying cause conservatively or surgically Prognosis depends on cause of hematuria and time of presentation

Complications
Hemorrhagic Shock Anaemia Clot Retention Of urine

Cases
A 7 year old boy presents 2 weeks after an episode of pharyngitis because his mother noticed his urine was red. He has mild edema on examination. 1. Schistosomiasis
2.

Goodpastures syndrome

3.
4.

Post-streptococcal glomerulonephritis
Prostatitis

 A 38 year old woman with chronic pelvic pain presents with macroscopic hematuria. She has no fever, dysuria or flank pain. She notes that her urine only turns dark red with or soon after her menstrual cycle.
1.

Endometriosis

2.
3. 4.

Exercise-induced hematuria
Polycystic kidney disease Polycystic ovarian disease

5.

Both 2 and 3

 A 28 year old man presents to the ER with the sudden onset of unilateral, severe flank pain radiating to the ipsilateral groin. He is afebrile, but diaphoretic and nauseous. His urine dipstick shows 3+ blood and trace leukocytes. 1. Drug-seeker
2.

Urolithiasis

3.
4.

Ectopic pregnancy
Schistosomiasis

A 50 year old man presents with 1 week of vague pelvic discomfort, urinary hesitancy, frequency and nocturia. His examination reveals a temperature of 38.1 C and a tender, boggy prostate. His urinalysis shows 20-30 RBCs/hpf without pyuria or crystals.
1. 2.
3. 4.

Urolithiasis Pyelonephritis
Hemolytic-uremic syndrome Acute prostatitis

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