Hospital Based Practice – Haematuria.

• Causes.
○ Renal causes.
 Neoplasia
 Glomerularnephritis
• Often IgA nephropathy.
 Tubulointerstitial nephritis
 Polycystic ovary syndrome
 Papillary necrosis
 Pyelonephritis
 Trauma
○ Extrarenal causes.
 Calculi
 Infection
• Cystitis
• Prostatitis
• Urethritis.
 Neoplasia.
• Bladder
• Prostate
• Urethra
 Trauma.
• Eg. From catheter.
• Investigations.
○ Urine dipstix.
 False dipstix +ve haematuria can be due to.
• Myoglobulinuria
○ Rhabdomyolisis
• Beetroot
• Porphyria
• Alkaptonuria
• Rifampicin
• Phenindione
• Phenolphthalein.
○ Urine MC&S
○ Bloods
 FBC
 U&E
 ESR
 CRP
 Clotting
○ Others.
 AXR/ KUB X – ray
 Rine cytology
 Estimation of protienuria
 Renal ultrasound
 Renal biopsy.
 • Management.
○ Usually refer first to a urologist, rather than nephrologist.
○ Refer to a nephrologist if.
 Risk of urothelial cancer is low.
 Risk of glomerulonephritis is not negligible.
• Aged < 40 years
• Raised creatinine
• Hypertension
• Proteinuria
• Systemic symptoms
• Family history of renal disease
○ Not all women with recurrent UTI and haematuria require cytoscopy.
 Have a good reason for NOT doing cytoscopy.

Renal stones.
• Due to crystal aggregates.
• Form in collecting duct.
• My be deposited anywhere from renal pelvis to urethra.
• Prevalence & incidence.
○ Life time risk of 15%
○ Peak age of onset is 20 – 40 years.
○ Male: Female ratio of 3:1
○
• Types of stone.
○ Calcium oxalate 75%
○ Magnesium aluminium phosphate. 10 – 20%
 Struvite
 Triple phosphate.
○ Others.
 Urate 5%
 Hydroxyapatite 5%
 Cysteine 1%
 Brushite
 Mixed

Type Causative factors Appearance on X – ray

Calcium oxalate Metabolic Spikey

Idiopathic Radiopaque
Calcium phosphate Metabolic Smooth

Idiopathic May be large

Radiopaque
Magnesium aluminium phosphate UTI Large horny (‘Staghorn’)

Radiopaque
Urate Hyperuricaemia Smooth

Brown

Radiolucent
Cystine Renal tubular defect, Yellow
 Crystalline

Semi – opaque

• Clinical pictures.
○ May be asymptomatic.
○ Pain.
 Kidney stones cause loin pain
 Ureter stones cause renal colic
• Radiates from loin to groin
• Nausea
• Vomiting
• Patient unable to lie still.
○ Compare with peritonitis.
 Bladder or urethral stone cause pain on passing urine.
• Poor urine flow.
• Intermittent urine flow.
○ Infection.
 Can co – exist with stones.
 Presents with.
• Cystitis.
○ Frequency
○ Dysuria
• Pyelonephritis.
○ Fever
○ Rigors
○ Loin pain
○ Nausea
○ |Vomiting.
• Pyonephritis.
○ Infected hydronephritis.
• Think about.
○ Diet.
 Oxalate levels can be increased by.
• Chocolate
• Tea
• Rhubarb
• Spinach
○ Time of the year.
 Increased sunlight in summer increases Vitamin D synthesis, and so calcium and
oxalate levels.
○ Occupation.
 Can they drink freely
 Is there risk of dehydration
○ Are there any precipitating drugs?
 Loop diuretics
 Antacids
 Acetazolamide
  Corticosteroids
 Theophylline
 Aspirin
 Thiazide diuretics.
 Allopurinol
 Vitamin C & D
 Indinavir

○ Predisposing factors.
 Recurrent UTI.
• Magnesium aluminium phosphate stones.
 Metabolic abnormalities.
• Hypercalciuria
• Hypercalcaemia
• Hyperparathyroidism
• Neoplasia
• Sarcoidosis
• Hyperthyroidism
• Addison’s syndrome
• Cushing’s syndrome
• Lithium
• Vitamin D excess
• Hyperuricosuria.
• Uraemia.
○ Alone
○ With gout.
• Hyperoxaluria
• Cystinuria
• Renal tubular acidosis
 Urinary tract abnormalities.
• Pelviureteric junction obstruction
• Hydronephrosis
• Calyceal diverticulum
• Horse shoe kidney
• Ureterocele
• Vesicoureteric reflux
• Ureteral stricture
• Medullary sponge kidney.
○ Family history.
 Increases risk of stones threefold.
 Specifically.
• X – linked nephrolithiasis
• Dent’s disease
○ Proteinuria
○ Hypercalciuria
○ Nephrocalcinosis
○ Infection above the stone.
 Fever
 Loin tenderness
  Pyuria
 Infection requires urgent intervention.

• Investigations.
○ Bloods.
 FBC
 U&E
 Calcium
 Phosphate
 Glucose
 Bicarbonate
 Urate.
○ Urine.
 Dipstix
 MSU
 24 hour urine for.
• Calcium
• Oxalate
• Urate
• Citrate
• Sodium
• Creatinine
• Stone biochemistry.
○ Imaging.
 KUB X – ray.
• Look along ureters for calcifications.
• Check transverse processes of vertebral bodies.
• 80% of stone are visible on X – ray
 Abdominal ultrasound.
• Hydronephrosis
• Hydroureter
 CT.
• 99% of stone are visible on CT
• Superior to IVU in imaging stones.
• Helps exclude differential causes of acute abdomen.`
○ Presentation is similar to ruptured AAA.
• Management.
○ Prompt analgesia.
 Diclofenac
• IV, IM or PR
 Morphine + metaclopramide.
○ If not tolerating oral intake.
 IV fluids.
○ If infection suspected.
 Cefuroxime.
○ Urgent urological referral.
 Dealy can result in infection and permanently damaged kidney function.

○ Surgery.
 Open surgery is rarely done.
 Extracorpreal shockwave lithotripsy (ESWL).
• Using US waves to shatter the stone.
• Ureteric stones < 1 cm are suitable for ESWL.
• Renal stones respond well to ESW|L if < 2 cm diameter
 Percutaneous nephrostomy.
• Surgically relieves obstruction.
 Ureteroscopy + laser.
• Ureteric stones > 1 cm
 Percutaneous nephrolithotomy. (PCNL).
• Laproscopic removal of stones.
• Renal stones > 2 cm diameter

○ Non – acute management.

 Between attacks, stones can be managed conservatively.
 Increase fluid intake.
 Sieve urine to catch stone.
• Send stone for biochemical analysis.
 Most stones pass within 48 hours.
• Some take up to a month.
 Stones < 5 mm diameter will pass spontaneously 90% of the time.
• Treat conservatively.
• Monitor progress on serial AXR every 1 – 2 weeks.
• Prevention.
○ Drink plenty of fluids, especially in warm weather.
 Aim for 2 – 3 litres of colourless urine per day.
○ Normal calcium diet.
 Low intake increases oxalate excretion.

○ Calcium stones.
 Thiazide diuretic
 Eg. Bendroflumethazide.
○ Oxalate stones.
 Reduce oxalate intake.
• Tea
• Choloclate
• Nuts
• Strawberries
• Rhubarb
• Spinach
• Beans
• Beetroot
 Pyridoxine may help.
○ Magnesium aluminium phosphate stones.
 Treast infection promptly.
○ Urate stones.
 Allopurinol
 Urine alkalisation.
• Urate is soluble when pH > 6.
• Eg. Potassium citrate.
• Eg. Sodium bircabonate.
○ Cystine stones.
 Vigorous hydration to keep urine output > 3 L/day.
 Urinary alkalisation.
 D – penicillamine.
• Chelates cystein.
• Give with pyridoxine to prevent Vitamin B6 deficiency.