Haematuria Dr. Abdelmoniem E. Eltraifi College of Medicine & KKUH Consultant Urologist College of Medicine & KKUH King Saud University, Riyadh, Kingdom of Saudi Arabia

Cases Quiz

Case 1 42 years old male, under your follow up for DM. During his routine follow up appointment. Told you that:

He had an episode of gross haematuria, one month ago He had an episode of gross haematuria, one month ago. He want to a private clinic near his house. They gave him an IV fluids. They did for him: MSU and urine culture, which he showed to you, with only +ve uncountable RBCs.

An US of kidneys, bladder and Pelvis and all were normal

Following that single episode, he had a clear urine Following that single episode, he had a clear urine. His history other wise unremarkable apart from DM

What you will do for him? Reassurance. Follow up. Further work up.

Prevalence of Haematuria ranges from 2.5% to 20%

Haematuria classified into: Gross, Macroscopic Symptomatic ( Painful) or Asymptomatic ( painless) Microscopic, invisible Also Symptomatic ( Painful) or Asymptomatic ( painless)

3 or more RBCS/High power, in 2 out of 3 Microscopic: 3 or more RBCS/High power, in 2 out of 3 properly collected samples ( AUA). Prevalence ranges from 0.19% to 16.1%. Neoplasm of genitourinary tract (GU) found in about 3-5% of asymptomatic patients. No identifiable cause in about 40%.

Gross ( Macroscopic, Visible, Clinical): 1 ml of blood in 1 liter of urine is visible for the patients.

22 to 40% of patients presented with asymptomatic gross haematuria are found to harbor GU neoplasm.

Causes of Haematuria Varies according to: Patient Age Type: Gross or Microscopic Symptomatic or Asymptomatic The existence of risk factors for malignancy.

Urinary tract malignancy Causes of Haematuria… Urinary tract malignancy Urothelial cancer Renal cancer Prostate cancer

Urinary tract infection Urinary calculi Benign prostatic hyperplasia Causes of Haematuria… Urinary tract infection Urinary calculi Benign prostatic hyperplasia Radiation cystitis and/or nephritis Endometriosis & Vesico-Uterine Fistula Urethral polyps

Anatomic abnormalities Causes of Haematuria… Anatomic abnormalities Arteriovenous malformation Urothelial stricture disease Ureteropelvic junction obstruction Vesicoureteral reflux Nutcracker syndrome

Medical or renal disease Causes of Haematuria… Medical or renal disease Glomerulonephritis Interstitial nephritis Papillary necrosis Alport syndrome Renal artery stenosis

Metabolic disorders Coagulation abnormalities Hypercalciuria Causes of Haematuria… Metabolic disorders Coagulation abnormalities Hypercalciuria Hyperuricosuria

Miscellaneous Trauma Exercise-induced hematuria Causes of Haematuria… Miscellaneous Trauma Exercise-induced hematuria Benign familial haematuria Loin pain–haematuria syndrome

Causes of Red-Orange urine discoloration Foods Drugs Others Red/Brown Beets Blackberries Rhubarb Fava beans Aloe Laxatives (eg, Ex-Lax, phenolphthalein) Tranquilizers (eg, chlorpromazine, thioridazine, propofol Porphyrin (eg, lead, mercury poisoning) Globins (eg, hemoglobin, myoglobin) Orange Carotene containing foods (eg, carrots, winter squash) Beta-carotene supplements Vitamin B supplements Warfarin Rifampin Pyridium Urochrome (eg, dehydration) Red colored candy and drinks

Menstrual Contamination Transient Microscopic Haematuria could be due to: Vigorous Exercise Sexual Intercourse Viral infection UTI Mild Trauma Menstrual Contamination

Risk factors for Urothelial cancer in patients with microscopic haematuria Smoking history Occupational exposure to chemicals or dyes (benzenes or aromatic amines) History of gross haematuria Age greater than 40 years History of urologic disorder or disease History of irritative voiding symptoms History of urinary tract infection Analgesic abuse ( Phenacetin) History of pelvic irradiation.

Haematuria Patients Work Up History Age Residency. Occupation Duration. Episodes, Urine color darkness Painless or painful Timing of haematuria Clots and shape of clots Trauma Bleeding from other sites Associated Symptoms urinary and Systemic History of :Bleeding disorders, SC, TB, Bilharzias & stone disease. Family History of : Malignancy, hematological disorders, renal diseases Drugs Red Colored food or drinks intake. Menses, Exercise, Sexual intercourse ( Transient Microscopic). Smoking

( Gross haematuria mandate full urological work up).

Asymptomatic microscopic haematuria in children does not mandate aggressive evaluation other than long-term follow-up, whereas it is important to evaluate asymptomatic gross haematuria

For young women with microscopic haematuria, symptoms and urinary finding of UTI just do: Urine culture Treat UTI Repeat MSU 6 weeks after treatment No need for further work up

Initial Evaluation of Asymptomatic Microscopic Haematuria Exclude Benign transient causes Menses, vigorous exercise, trauma, sexual activity, viral illness, infection If one or more of the following present: Proteinuria, Dysmorphic RBCs, Red cells cast, Elevated creatinine Nephrology Evaluation If there in risk for GU neoplasm Urology Evaluation

Urologic Evaluation of Asymptomatic Microscopic Haematuria Follow up by Measuring BP. MSU. Urine Cytology. U & E.

Lap Investigations MSU Urine Culture ( Pyogenic Organisms). Urine FOR AFB ( Tuberculosis). Urine Cytology and Tumor markers CBC & Hematology U&E LFT

Radiology

US

US

US

IVU

CT Urography

CT Urography

CT Urography

CT Urography

CT Urography

CT Urography

CT Urography

When to refer to urologist: If there is a positive findings, that requires urological intervention If the patient is high risk for GU neoplasm, with no findings in the lap and radiology work up.

Cystoscopy

Cystoscopy

Cystoscopy

Angiography

Angiography

Angiography

Angiography

Ureteroscopy

Ureteroscopy

Case 2 66 years old female patient on Warfarin for a history of DVT, presented to the emergency room with gross haematuria. No abnormal sign on clinical examination.

Her investigations: MSU, obscured by RBCs. Hb was 11 gram/L. INR was 2.5.

This patient needs: To look after Coagulation problem. Insertion of 3 ways urethral catheter to irrigate her bladder. Urological investigation work up.

Case 3

A 60-year-old woman is referred to the emergency department (ED) because of a recent event of painless macroscopic haematuria. No Other positive points in her history

On physical examination: No abnormality detected.

A laboratory analysis including: MSU: uncontable RBCs. urine culture: No growth. Urine cytology is positive for malignant cells. CBC, U&E, LFT: all within normal Cystoscopy is performed, which demonstrates a normal urethra leading to a urinary bladder covered by normal mucosa, with no exophytic lesions and no active bleeding.

Intravenous urography (IVU) Computed tomography (CT) urography Which of the following examinations is today regarded as being the imaging modality of choice for such patients?  Intravenous urography (IVU) Computed tomography (CT) urography Abdominal ultrasonography Abdominal magnetic resonance imaging (MRI)

What is the diagnosis? Hint: Look for differences between the right and left kidneys Renal stone Urothelial carcinoma External renal compression Complicated renal cyst

Which of the following statements is NOT true? Men are twice as likely as women to develop an upper-tract tumor. Upper-tract tumors rarely present before the age of 40 years. Disease-specific annual mortality is greater in men than in women. Upper-tract Urothelial carcinoma accounts for 5-7% of all renal tumors.