HEMATURIA

 You are a GP, your next patient is a 67 year old male

who comes in complaining of blood in urine.
Tasks
 History
 Physical Finding from the examiner
 Diagnosis and Differentials
 Management
 History
 For how many episodes? What colour have you noticed(frank blood or
cloudy brown), any clots?
 During passage of urine, does this happen at the beginning or at the
end? (initial-urethtral origin, terminal-bladder or prostate origin)
 Do you have frequency of urination? How many times during the day
and how many times during the night
 difficulties urinating, such as trouble starting the flow of urine?
 the urge to urinate often, particularly at night?
 Any problem with the stream, any dribbling afterwards?
 feeling as though the bladder can't be fully emptied?
 Any pain or burning sensation on passing urine? Fever with chills or
rigor? any loin pain or loin to groin pain?
 Have you noticed any changes in weight recently? Any change
in your appetite? Backache?
 Any smptoms like cough, sob, chest pain, palpitations,
headache? Any lumps or bumps around the body
 Have you had any large amounts of beetroot, berries?
(pseudohematuria)
 Any recent trauma
 SADMA : Known hypertensive.Are you on any medications?
any blood thinners?( patient’s taking aspirin)
 Any family history of bleeding disorders or cancers?
 Any previous instrumentation or surgery in the urinary
tract?(stricture)
 Physical Examination
 General Appearance: BMI, Pallour, lymphadenopathy
 Vital signs: BP with postural drop, pulse with rate and rhythm,
temperature
 Abdomen Examination: tenderness, any mass or organomegaly
percussion of the bladder wall (after the patient has voided)
DRE * Size and consistency of the prostate? Surface Nodularity? Is
the median sulcus palpable? Mobility or the attachment of the rectal
mucosa to underlying gland? (consistnecy firm but not hard, no
induration, moderate enlargement, mobile, surface-smooth)
Neurological examination of upper and lower limb
Respiratory and CVS examination
Office test : urine dipstick test, BSL
INVESTIGATIONS
 FBE, ESR & CRP
 Renal function tests (s. Creatinine, eGFR)
 Serum electrolyte level, blood glucose level
 PSA
 Urine MC & S, urine cytology
 XRAY KUB (for assessing radio opaque renal, ureteric stones,
sensitivity 60%)
 USG KUB
 Non contrast CT of KUB
 CT intravenous pyelogram/ CT urogram By urologist
 Cystoscopy
 Transrectal USG with biopsy(if needed)
 Diagnosis and Management
From history and examination, most likely you have a
condition called benign prostatic hyperplasia, which a benign
enlargement of the prostate gland. This gland is a small gland
located at the base of the bladder, function is to form some part
of semen. Sometimes this gland enlarges with increased
vasculatrity leading to blood in urine, also partial blockage of the
tubes (urethra)that passes through the prostate gives rise to
symptoms like frequency, weak stream, hesitency with initiating
urination
I would have to further (aformentioned) investigations and refer
you to the specialist/urologist to review and confirm
 There are multiple causes of hematuria/blood in urine.
 Infection in the tract can cause hematuria but you don’t have any
burning sesnation or fever
 Infection of the kidneys (pyelonephritis) but you don’t have any
fever with chills or rigor
 Stone in urinary tracts (ureter, bladder) can lead to blood in urine
but you don’t have severe loin to groin pain
 In suspicious lesions or tumor of the urinary tract and prsotate,
hematuria can occur, but there would be weight loss, backache
 Due to previous instrumentation or any surgery of the urinary tract,
blood in urine can occur
 Also no history of trauma noted
 (This case can come with problems with ‘urinary symptoms’ other
than hematuria)
 Handbook case- condition 67- urinary symptoms with tiredness due
to hydrochlorthiazide
 CASE: You have a 33 year old male coming to
your GP practice with 1-day history of
hematuria. He had an episode of URTI 2 days
ago. On examination his BP is 160/90,
generalized edema, urine dipstick Blood and
protein ++
 History
 Management
History
 I can understand you had sore throat 2 days back, did you take any medications for it?
 For how many episodes? What colour have you noticed(frank blood or cloudy
brown), any clots?
 Any pain or burning sensation on passing urine? Fever with chills o rigor? any loin
pain or loin to groin pain?
 Do you have frequency or urgency of urination? How many times during the day
and how many times during the night
 During passage of urine, does this happen at the beginning or at the end? (initial-
urethtral origin, terminal-bladder or prostate origin)
 Any trouble with the flow of the urine? Any puffiness of the face? Or legs?
 Are you sexually active? If you don’t mind me asking, could it be sexually acquired?
Any hx of STD?
 Do you engage in vigorous sports or physical acivities? Have you noticed bleeding
from anywhere else? Nosebleeds or easy bruising?
 Have you had any large amounts of beetroots, berries or lollies?
 SADMA
 Positive here: history of sore throat a day ago, high blood
pressure,
Differentials in this scenario/age:
 IgA nephropathy
 PSGN
 Basement membrane disease,
 Polycystic kidney disease,
 Stone in urinary tract/ stricture
 March hemoglobinuria
Investigations: CBC, ESR, RFTs, ASO titre, complement level,
Urine MCS(RBC casts and RBC-indicates glomerula injury)
Urine culture, 24 hour urinary protein, USG, Non contrast CT (if
stone is suspected)
 Most likely you have a condition called IgA nephropathy.
Because of the recent upper resp tract infection, the body
produced some antibodies towards bugs and these antibodies
deposited in the kidney’s filtering system, glomerulous
resulting in blood in urine.
 You require admission, where will be assessed by a
nephrologist.
 They will do the required investigations
 High blood pressure medications.
Taking angiotensin-converting enzyme (ACE) inhibitors or
angiotensin receptor blockers (ARBs) can lower your blood
pressure and reduce protein loss.
 Immunosuppressant- corticosteroids
 Diuretics