HEMATURIA

IKOBHO A. D. B.MED SC, MBBS, FWACS.

LECTURER & CONSULTANT SURGEON
(UROLOGIST)
 OUTLINE
• INTRODUCTION
• CLSSIFICATION
• AETIOLOGY
• EVALUATION
• INVESTIGATION
• TREATMENT
• CONCLUSSION
 INTRODUCTION
• DEFINITIONS:-
1. Hematuria is the passage of blood in the urine.

2. Significant hematuria is the presence of blood

in the urine greater than 3-rbc’s per high power
microscopic field, in urine properly collected i.e.
clean catch specimen.
• Significant hematuria of any degree should
never be ignored and in adults, should be
regarded as symptom of urologic malignancy
until proved otherwise.

• From the foregoing all pts with a single

episode of hematuria require evaluation.
 CLASSIFICATION
• Gross or macroscopic i.e. visible, most significant.

• Microscopic >3-5 rbc’s macroscopically normal urine.

• Dip stick hematuria; sensitivity is > 90%.

• False hematuria;- discoloration from food, drugs

myoglobin etc.

• Factitious hematuria;- malingering, rbc’s added from

outside the urine

• Hematuria ;- initial terminal or total.

 AETIOLOGY
• Etiologically it can be classified into:-
1. Glomerular causes/ syndromic causes.

2. Non- glomerular causes:- medical or surgical.

3. Age specific causes

 Glomerular causes include;-
• IgA nephropathy ( Berger's disease)

• Mesangioproliferative glomerulonephritis.

• Focal segmental proliferative glomerulonephritis.

• Familial nephritis (e.g. alport’s syndrome)

• Membranous glomerulonephritis.

• Focal segmental sclerosis.

• Unclassified.

• Systemic lupus erythematosis.

• Post infective glomerulonephritis

• Subacute bacterial endocarditis

 Non- glomerular medical causes
• It could be tubulointerstitial, renovascular, or systemic.

1. renal origin:- thrombosis, embolism, aneurysm of the renal artery,

malignant hypertension, renal cystic disease, trauma.

2. Medications:- anticoagulants, dindavin, wafarin or heparin,

salicylates etc.

3. Hematological disorders:- systemic causes; parpura, hemophiliacs,

leukemia, lymphoma, scurvy etc.

4. Coagulopathies:-sickle cell disease, SS, SC, AS, causing papillary

necrosis from sickling & infarction.

5. Hemorrhagic cystitis due to radiotherapy & chemotherapy

 Surgical causes includes:-
• Urologic tumors:- renal tumors, renal cell cancer, ureteric
tumors, bladder tumors/ transitional cell cancers, BPH,
prostate cancers, etc.

• Stone disease.

• Urinary tract infections; ranging from TB, schistosomiasis,

cystitis, prostatitis, urethritis, strictures etc.

• Trauma/injury to the kidneys, ureter, bladder, urethra

 Age specific causes:-
• Vesical schistosomiasis- 25yrs.

• Trauma- 30yrs

• Urinary tract infections- 35yrs.

• Calculi – 45yrs.

• Bladder cancers- 50yrs.

• BpH – 65yrs

• Prostate cancer – 69yrs

 EVALUATION
• History:- age, sex, occupation, degree of hematuria etc.

• Timing:- initial, total &terminal

1. Initial hematuria, usually arises from the urethra, it is
least common & often 2⁰ to inflammation.
2. Total hematuria is most common & significant
3. Terminal hematuria is usually 2⁰ to bleeding from
bladder neck.

• The presence of blood clot indicates more significant

hematuria; amorphous or vermiform
• Pain:- painless hematuria is suggestive of
schistosomiasis or neoplasm while painful
hematuria may be due to infection or calculi.

• Colors:- dark or brown urine suggest lesion in the

kidney or ureter while bright red hematuria may
be due to a lesion in the bladder or urethra.

• Duration:- short duration within wks suggest

neoplasm, or acute infections while long duration
of yrs suggest chronic disease such as TB,
hydronephrosis, calculi, PKD, Vesical
schistosomiasis
• Hx of hematuria in children & young adult, usually males + low grade fever
+ erythematous rash may suggest Hb-A nephropathy (Berger’s disease).

• Family hx of renal disease + deafness may suggest familial nephritis

(Alport's syndrome).

• Family hx of renal disease + hemoptysis + abnormal bleeding may suggest

Goodspasture syndrome
.
• Family hx of bleeding tendencies + hematuria may suggest blood
dyscrasias.

• Hx of URTI + fever/ or skin rash may suggest post streptococcal

glomerulonephritis.

• Family hx of renal cystic disease + hematuria may suggest medullary

sponge kidney.
• Family hx of urolithiasis + intermittent hematuria + or passage of stone
may suggest stone disease.

• Hx of DM + African descent + SCD or trait & or suggested analgesic abuse

may suggest papillary necrosis.

• Hx of medications especially anticoagulant + hematuria may be

suggestive.

• Hx of ↑Bp + flank or abdominal pain may suggest vascular disease,

embolism, thrombosis, A/V fistula.

• Hx of LUTs + hematuria may suggest prostatic pathology.

• Hx of exercise or instrumentation or injury may suggest cause.

• Hx of malignancy or intravesical chemotherapy or radiotherapy may be

associated with intractable hematuria
 Clinical examination include:-
• General examination for pallor (anemia), wasting,
uremia, edema, fever, rash etc.

• Chest infection, hypertension

• Abdominal distension, enlarged liver, spleen,

kidneys, bladder urethritis etc.

• DRE and pelvic examination to R/O BpH, CaP,

bladder masses etc
 INVESTIGATIONS
• URINALYSIS/MCS:-
1. Dysmorphic rbc’s + cast + proteinuria may suggest glomerulonephritis.

2. Presence of circular rbc’s + absence of cast/proteinuria or minimal proteinuria

may suggest non glomerular hematuria.

3. Presence of crystals may suggest stone disease.

4. Presence of ova + terminal spine = schistosomiasis

5. Presence of bacteria may suggest infection.

6. Special stains with Z/N may show TB which can be cultured Lowenstein zestein
medium.

7. Culture of MSU may show 10⁵ colony forming units in UTI’S

• Renal fxn test:- e/u/cr, 24 hr urine protein
determination > 2⁺ suggest GN.

• FBC :- anemia, genotype may reveal SCD or trait etc

• Urine cytology = urethelial malignancies.

• Tumor markers = BTA, NMP-22

• PT, PTT, ASO titers etc

• Renal biopsy may reveal deposits of IgA, IgG using

immunoflorescent.
• Cystoscopic examination; for evaluation of urethra,
bladder, urologic imaging, brush cytology & for
lateralizing hematuria.

• It may show punctate hemorrhagic lesion in exercise

induced hematuria.

• It may show CIS, BpH, sandy patches suggestive of

schistosomiasis

• It can be used to biopsy all tumors for confirmation

• Nephroscopy can also be done

• IMMAGING:-

1. Plain abdominal X-Ray may show soft tissue swelling. Calcification may suggest
schistosomiasis, Tb, stone, bony metastasis or fracture healing.

2. USS; may show tumors, bladder & prostate lesions, calculi, hydronephrosis etc.

3. IVU= structure & function of the kidney.

4. Retrograde pyelogram may show displacement, distortion, & destruction of the

calyces, SOL, hydronephrosis, ureteric obstruction.

5. Urethrocystogram I US, urethral Injury, calculi.

6. CT/MRI= detection of tumors, staging, proper soft tissue definition & planning of
tx.

7. Arteriography/selective angiography = renovascular abnormalities

8. Radionuclide bone scan in early diagnosis of bony metastasis

 TREATMENT
• Choice of txt depends on findings. It may
require multidisplinary approach involving
nephrologist, oncologist, hematologist,
pediatrician, microbiologist, urologist,
interventional radiologist etc.

• Management may range from conservative,

medical to surgical intervention depending on
severity.
• Surgical txt may require:-

1. Informed consent

2. Optimizing patient for elective/urgent cases.

3. Correction of fluid , electrolyte derangement & blood

transfusion for severe anemia.

4. Timely intervention

5. Appropriate anesthesia is crucial.

6. Surgical txt depends on cause, severity & urgency

 Renal conditions such as:-
• Infections may require txt with appropriate antibiotics, Tb
with antikock’s therapy.

• Renal tumors may require partial or total nephrectomy.

• Ureteric jxn obstruction may require pyeloplasty or

reimplantation.

• Severe Renal injuries are explored & repaired, angiography &

super selective embolisation.

• Renal calculi may require conservative txt or extracorporeal

shock wave lithotripsy to nephrolithotomy or nephrectomy
 Bladder conditions such as:-
• Cystitis may require txt with appropriate antibiotics.

• Schistosomiasis will require pranziquentel, biltricide &

follow up Cystoscopy.

• Bladder calculi & diverticula are removed surgically after txt

of underlying cause.

• Bladder injuries are txted by exploration & repair

• Ca of bladder may require TURBT, intracavitory or systemic

chemotherapy, partial or total cystectomy/urinary
diversion + adjuvant or radical radiotherapy
 Mild:--Bladder
Diuresis to prevent clotting.
• Aminocaproic acid inhibits fibrinolysis so bleeding vv can seal
from fibrin

• Severe (bladder):-
• Plan to transfuse.IV fliuds

• Catheter placement: monitor resuscitation relief/prevent clot

retention.

• Cystoscopic evacuation: catheter cannot evacuate.

• Continous bladder irrigation with three way with

saline,1%alum,glycine
 Hem
• Cystoscopic cautery if bleeding fails to stop.

• Chemo-instillation

• Formalin instillation

• Phenol

• Silver nitrate.

• Use of protaglandins.

• Embolisation of int. iliac art.Pt. Op risk bleeding from prostate/bladder.

• Surgery ligate int iliac.art

• Cystectomy for tumours

 Prostatic hemat :Tx
• Mild
• Hydrate/antifibrinolytic agent (EACA).

• Severe from prostate.

• Catheter, irrigate, urethrocystoscopy surgery,
TURP OR Open surg.

• Prostatitis may require with txt

antibiotics/massage
 Urethral conditions
• Infections may require txt with drugs

• U/S may require surgical interventions.

• Urethral injury may require suprapubic

cystostomy & later surgical intervention.

• Calculi/masses may be removed surgically

 conclusion
• Hematuria, very treacherous never to be taken for
granted.

• No form of bleeding conclusively tells about the

underlying cause, type, magnitude with any certainty.

• It only suggests, take a good hx, exam purposefully

and investigate with suspicion, M/A.

• Thanks.