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

2. Cases Quiz

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

4. 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.

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

6. 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

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

8. Prevalence of Haematuria ranges from 2.5% to 20%

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

10. 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%.

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

12. 22 to 40% of patients presented with asymptomatic gross haematuria are found to harbor GU neoplasm.

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

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

15. 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

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

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

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

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

20. 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

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

22. 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.

23. 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

24. ( Gross haematuria mandate full urological work up).

25. 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

26. 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

27. 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

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

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

30. Radiology

31. US

32. US

33. US

34. IVU

35. CT Urography

36. CT Urography

37. CT Urography

38. CT Urography

39. CT Urography

40. CT Urography

41. CT Urography

42. 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.

43. Cystoscopy

44. Cystoscopy

45. Cystoscopy

46. Angiography

47. Angiography

48. Angiography

49. Angiography

50. Ureteroscopy

51. Ureteroscopy

52. 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.

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

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

55. Case 3

56. 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

57. On physical examination:
No abnormality detected.

58. 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.

59. 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)

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

63. 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.