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Definition
passage of red blood cell in the urine.
can be detected by dipstick/frank blood.
Frank haematuria (35% has urological malignancy).Therefore, frank haematuria, think
renal/bladder Ca.
Causes
Organ DDx Hx
Renal Glomerular disease Family Hx
Polycystic kidney Family Hx
Carcinoma Painful haematuria?loin pain?anorexia?weight loss?PUO
Stone Painful haematuria
Trauma(inc.Bx) Hx of trauma?Scan?
TB Hx or travel
Embolism
Renal vein thrombosis
Vascular malformation
UTI Fever,vomiting,loin pain
Ureter Stone Loin pain (stone)-colicky pain if obstructed, clot colic (neoplasm),
Neoplasm
Bladder Carcinoma Painless haematuria,pelvic pain, recurrent UTI, dysuria-
Stone (neoplasm), suprapubic discomfort (bladder stone), terminal
Trauma bleeding with pain (bladder stone)
Inflammatory eg. Total haematuria thru the stream-bleeding from bladder
Cystitis, TB, Terminal haematuria at the end of stream-rare but classical
schistosoma presentation of schistosomiosis.
Frequency, dysuria,urgency
Prostate BPH Terminal haematuria at the end of stream
Carcinoma Check for symptoms of prostatism-difficulty starting, poor stream,
nocturia
Urethra Trauma Urethral injury- pelvic # or falling astride or recent intercourse
Stone Urethral bleeding independent of micturation (urethral lesion)
Uretritis Initial haematuria at the start of stream-urethra
Neoplasm
Gen Anticoagulant Therapy Spontaneous bruising?
Thrombocytopenia Exposure to malaria?
Haemophilia Family hx
Sickle cell disease If young and fit-exercise?
Malaria
Strenuous exercise
Red urine Haemoglobinuria Crush injuries or ischemia of muscle
Myoglobinuria
Acute intermittent Take drug Hx, hx of malaria, TB
porphyria
Beetroot Ingestion?
Senna
Phenolphthalein
Rifampicin
Examination
Investigation
a)General Ix
Ix What we rule in/out?
FBC,ESR ↓Hb-gross haematuria,malignancy
↑Hb-polycytemia ass. with hypernephroma
↑WCC-infections
↓Platelets-blood dyscrasia
↑ESR-malignancy,TB
Urine Microscopy Red Cells-excludes haemoglobinuria and ingestions of substances that
cause discolouration of urine
White cells-infection
Organism-infection
cytology
MSU Culture and sensitivity -infection
U&E Renal failure
Clotting Screen Anticoagulant therapy, blood dyscrasia
CXR Metastases (cannonball metastases with hypernephroma),TB
KUB Renal calculus-80% of stone visible on Xray
Specific Investigation
Types of stone
Calcium oxalate 75%
Magnesium aluminium phosphate. 10 – 20%
Struvite
Triple phosphate.
Others.
Urate 5%
Hydroxyapatite 5%
Cysteine 1%
Brushite
Mixed
Clinical pictures
o May be asymptomatic.
o Pain.
Kidney Ureter Bladder/Urethral
loin pain renal colic pain on passing urine.
Radiates from loin to groin Poor urine flow.
Nausea Intermittent urine flow
Vomiting
Patient unable to lie still-in
peritonitis, pts lie still.
o Infection.
Can co – exist with stones.
Presents with.
Cystitis Pyelonephritis Pyonephrosis-pus Others
collect in renal pelvis
Frequency Fever Infected hydronephritis. Haematuria
Dysuria Rigors Protenuria
Loin pain Sterile Pyuria
Anuria
Nausea
Vomiting.
In Hx
Diet Oxalate levels ↑-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?
Drugs Loop diuretics, Antacids, Acetazolamide, Corticosteroids, Theophylline,Aspirin
Thiazide diuretics, Allopurinol, Vitamin C & D, Indinavir (HAART)
Risk factor Recurrent UTI- Magnesium aluminium phosphate stones.
Metabolic Hypercalciuria/Hypercalcaemia;Hyperparathyroidism
Abnormalities Neoplasia; Sarcoidosis;Hyperthyroidism
Addison’s syndrome,Cushing’s syndrome
Lithium, Vitamin D excess
Hyperuricosuria; Uraemia(alone /with gout)
Hyperoxaluria, Cystinuria,Renal tubular acidosis
Renal tract Horse shoe kidney, hydronephrosis, ureteral stricture, etc
abnormalities
Family history. Increases risk of stones 3X.
Specifically-ask
X – linked nephrolithiasis
Dent’s disease
Proteinuria
Hypercalciuria
Nephrocalcinosis
Infection above the Fever, loin tenderness, pyuria
stone-urgent
intervention
Treatment
1. Analgesics ie. NSAIDS diclofenac 75mg IV/IM/suppository (100mg) or Morphine 5-10mg with
10mg metaclopromide.
2. Give fluids (if unable to tolerate orally) +antibiotics eg cefuroxime 1.5g/8H
3. If obstruction-----refer urologist for further management
Options
a) Extracorporeal Shockwave Lithotripsy (ESWL)
b) Percutaneous Nephrostomy to relieve obstructions
c) Uteroscopy±laser
d) Percutaneous nephrolithotomy
e) Open sx-rare
Clinical Features
Most common Haematuria, loin pain, mass in flank
Others Malaise, weight loss, aneroxia,fever,
Occasionally polycytemia,
Varicocele (2%)- the enlargement of one testicle
25% have metastases at presentation to bone,liver,lung (Xray-cannonball
metastases)
Spread-direct(renal vein), lymph nodes and haematogenous.
Investigations
Blood FBC(polycytemia), ESR, U&E, alk phos
Urine RBCs,Cytology
Imaging USS, CT/MRI, IVU, renal Angiography, CXR,Bx for cell type
Treatment
Sx-radical nephrectomy gold standard -Unless bilateral involvement/contralateral kidney fx poorly
Metastatic disease medroxyprogesterone may control metastasis
Consider Immunotherapy with interferon α or interleukin 2
Bladder Tumour
Commonest form of urological ca
majority of Transitional Cell (urothelial)type
other type includes adenocarcinoma and squamous cell carcinoma(may follow schistosomiasis)
Common after age 40;M:F =4:1
Spread-direct invasion to adjacent structure,lymphatic spread and haematogenous spread late.
Risk Factors
1. Smoking
2. Industrial chemical eg. Aromatic amines (rubber/dye industries)
3. Drugs eg. Phenacetin,cyclophosphomide
4. Chronic inflammation eg. Stone,Schistosomiosis-scc, chronic cystitis
5. Pelvic Irradiation
6. Bladder diverticulae
7. Persistent urchal remnant-adenocacinoma
Presentation
-painless haematuria, painful if clot retention,recurrents UTI and voiding irritability
-also dysuria,frequency,urgency
Examination
usually –Ve in early stage.
Tumour may be palpable on EUA
Investigation
Blood FBC-Hb↓,ESR↑,U&E
urine Creatinine, MSU & CS, urine microscopy&cytology (ca may cause sterile pyuria) ie WCC ↑, but
sterile culture.
Others Cystoscopy with Bx-diagnostic
IVU-filling defect, bimanual EUA-may help in staging,CT/MRI-lymph/pelvic nodes involvement
Pathogenesis
Infection of UT usually via ascending transurethral route-facilitated by intercourse n catherization.
Women-more susceptible ?
1.short urethra
2.proximity to anus facilitates transfer of bowel organism to bladder.
Risk factors
Female, sexual intercourse,exposure to spermacide in female thru condom/ diaphragm,
pregnancy,menopause,↓ host defence, immunosuppression, DM, Urinary tract obstruction, stones,
cathether, UT malformations
Organism
Symptoms
Signs
Fever, abdominal/loin tenderness,foul smelling urine (esp lower UT), may also present with distended
bladder,enlarged prostate.
NB :vaginal discharge esp. offensive one → check for foreign body ie.tampon! or STI
(candida,TV,BV,gonorrhea)
Test
Urine Dipstick Nirates and leucocytes +ve- treat empirically
Treatment
Prevention
Prophalaxis antibiotics,continous /post coital
Drinking 200-750 ml cranberry/lingonberry juice /day@ take cranberry con concentrate juice
-↓10-20% infection.
Complications-more likely with complicated infections
1. Renal papillary* necrosis
2. Renal/perinephric** abscess with the risk of Gram –ve septicemia.
* renal papilla-location where Medullary pyramids empty urine into the renal pelvis
* cone-shaped retroperitoneal compartment containing the kidney, adrenal gland, perinephric fat, fibrous bridging septa, and a
rich network of perirenal vessel and lymphatics