1. Haematuria Dr. Abdelmoniem E. Eltraifi 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 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 normalAn US of kidneys, bladder and Pelvis and all were normal

6. 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. What will you do First? Urine analysis. Other Investigations.

9. If his urine analysis came clear, with nil RBCs Will you do: Reassurance Follow up? Further investigations?

10. What investigations? Urine Cytology Repeat US of the kidneys and pelvis. IVU CTU

11. If CTU and urine cytology were –ve. Are you going to do: Further investigations? Follow up? Reassurance?

12. What investigation and why?

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

14. Haematuria classified into: 1. Gross, Macroscopic Symptomatic ( Painful) or Asymptomatic ( painless) 2. Microscopic, invisible A lso Symptomatic ( Painful) or Asymptomatic ( painless)

15. Microscopic : 3 or more RBCS /High power, in 2 out of 3 properly collected samples ( AUA). P revalence 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%.

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

17. 22 to 40% of patients presented with asymptomatic gross haematuria are found to harbor GU neoplasm.

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

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

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

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

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

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

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

25. Causes of Red-Orange urine discoloration ColorFoodsDrugsOthers Red/BrownBeets 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 containin g foods (eg, carrots, winter squash) Beta-carotene supplements Vitamin B supplements Warfarin Rifampin Pyridium Urochrome (eg, dehydration)

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

27. 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.

28. 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 Colored food or drinks intake. Menses, Exercise, Sexual intercourse ( Transient Microscopic). Smoking Haematuria Patients Work Up

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

30. 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

31. For young women with microscopic haematuria, symptoms and urinary finding of UTI just do: 1. Urine culture 2. Treat UTI 3. Repeat MSU 6 weeks after treatment 4. No need for further work up

32. Initial Evaluation of Asymptomatic Microscopic Haematuria

33. Urologic Evaluation of Asymptomatic Microscopic Haematuria Follow up by 1.Measuring BP. 2.MSU. 3.Urine Cytology. 4.U & E.

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

35. Radiology

36. US

39. IVU

40. CT Urography

47. 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.

48. Cystoscopy

51. Angiography

52. Angiography

55. Ureteroscopy

56. Ureteroscopy

57. 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.

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

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

60. Case 3

61. A 60-year-old woman is referred to the emergency department (ED) because of a recent event of painless macroscopic haematuria. She reports having experienced several similar episodes during the past year, all of which resolved spontaneously. She regards these episodes as being of gynecologic origin because she is 5 years postmenopausal. She describes a general feeling of malaise in the days preceding the current episode, But she denies having any fever, dysuria, or increased frequency or urgency of urination. The patient also describes an unintentional weight loss of 5 kg during the past 2 years. The patient's previous medical history includes hypothyroidism that was treated medically with thyroxin. And her surgical history includes 2 treatments of dilatation and curettage (D&C) and a tonsillectomy. She denies smoking, drug use, or alcohol consumption. She has no previous history of kidney stones or recurrent urinary tract infections.

62. On physical examination: the patient appears well. She has a temperature of 98.8°F (37.1°C), A pulse rate of 71 bpm, and a blood pressure of 150/86 mm Hg. The head and neck examination is normal. Lung auscultation reveals normal breath sounds bilaterally, without wheezing or crackles. Her heart sounds are regular, with a 2/6 systolic murmur maximally auscultated over the right second intercostal space. The abdomen is non distended and non tender, no masses are palpated, and there are no signs of peritoneal irritation. No peripheral edema is noticed, Peripheral pulses are palpated, and the neurologic examination is normal. A gynecologic evaluation that includes a speculum examination and transvaginal ultrasonography is performed, which reveals no pathologic findings.

63. A laboratory analysis including: A complete blood cell (CBC) count, coagulation studies, and a basic metabolic panel, shows a normal hemoglobin level, normal platelet count, and no coagulopathy. No electrolyte abnormalities are present. A urine culture is negative. Urine cytology is positive for malignant cells. 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.

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

67. Which of the following examinations is today regarded as being the imaging modality of choice for the diagnosis of upper-tract lesions? Intravenous urography (IVU) Computed tomography (CT) urography Abdominal ultrasonography Abdominal magnetic resonance imaging (MRI)

68. 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.