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Helen Forristal
MSc (ANP) BSc (Hons)
IAUN 2013
Haematuria presence
of Red Blood Cells in
the urine.
Distinctions
Macroscopic
Microscopic (Cameron 1996)
Painful
Painless
Nephrological Initial
Urological Terminal
Differential Diagnosis Total
Haematuria
There is a poor correlation between the degree of
haematuria and the severity of any underlying cause. An
older person with visible haematuria is more likely to have
serious underlying pathology than a younger person with
microscopic haematuria and no symptoms. All people with
haematuria need further investigation.
Bladder
Trauma
Infections-, TB, Schistomiasis, Stone disease
Carcinoma - 90% , TCC, SCC, Adenocarcinoma
Radiation Haemorrhagic Cystitis
Exercise Induced haematuria
Pharmacology - Cyclophosphamide
Clinical Assessment
Physical Assessment ( DRE and PV examination)
Urine test strip
Urinalysis for culture and sensitivity
Cytology
Laboratory investigations
Interventional tests eg. Cystoscopy
Radiology investigations
Natasha, a 53 year old lady presented during
routine follow up with a three week history of
macroscopic haematuria, dysuria, frequency,
hesitancy, polyuria, incomplete voids, urinary
incontinence and abdominal discomfort. This
was further aggravated by walking and pain
was relieved by simple analgesia. Natasha was
diagnosed with asthma 24 years ago but this
has not been troublesome. (2 Algorithm).
Presently fit, takes alcohol socially and stopped
smoking 12 years ago. In 2008 she was
diagnosed with a muscle invasive bladder
cancer and subsequently received radical
radiotherapy which was complete June 2009.
Clinical Assessment (1)
The initial clinical evaluation should provide indications as
to the
Cause of haematuria
Help to eliminate potential benign causes, for example vigorous
exercise, menstruation and trauma. (3 Algorithm).
Most stones are formed in older patients. However, clinical observations have indicated not
only a changing frequency and composition of urinary calculi but also a shift in gender and
age related incidences.
Rare in children.
Types of Urothialisis:
Calcium containing calculi
Calcium Oxalate
Calcium Phosphate
Uric Acid calculi
Cystine Calculi
Urothialisis (3)
Diagnostic Modalities
Thin slice CT stone protocol preferably within 24 hours if acute presentation to
confirm diagnosis or for planning of treatment if a stone is confirmed on KUB x-ray.
KUB allows 60% visibility compared with > 95% stone identification on CT. (BAUS
Section of Endourology, 2008).
Cystoscopy to visualise the bladder
Retrograde studies may be an additional study to visualise both ureters to determine
the positioning of the stone and feasibility of removing the stone.
Blood Analysis, Serum Creatinine and Urea (Algorithm 13)
An ultrasound scan combined with an ordinary abdominal x-ray is a viable alternative to IVU or CT.
The advantages of ultrasound are that it does not involve any radiation or contrast medium and that
it is non-invasive .
Ultrasound is also more sensitive than IVU in the detection of small tumours of the renal
parenchyma. Ultrasound is less sensitive than IVU in the detection of small tumours of the drainage
system of the kidney, however , the accuracy of ultrasound is dependent on the skill of the person
performing the procedure.
Ultrasound and IVU should be seen as complementary rather than mutually exclusive. In some
patients it may be necessary to perform both tests in order to make an accurate diagnosis . If
ultrasound or IVU suggests a mass in the kidney , then a
CT scan is usually used as a first line investigation in haematuria.
An ultrasound scan or intravenous urogram cannot rule out the presence of a bladder tumour. All
patients with haematuria should undergo cystoscopy. ( Algorithm 14).
Types of Bladder Cancer
Types of Tumour
Because of the complex nature of development of the bladder a variety of tumours
occur.
The IVU is the traditional standard for upper tract urothelium imaging;
however it is poor for evaluating the renal parenchyma. (Steinberg et al
2010). (16 Algorithm).
Urinary Tract Infections-some
facts (3)
Factors unfavourable to bacterial growth include a low Ph (5.5 or less, a high concentration of Urea
and the presence of organic acids derived from a diet that includes fruits and protien.
Sexual intercourse contributes to increased risk, as does use of a diaphragm and /or spermicide.
The prognosis for most women with cystitis and pyelonephritis is good; about 25% of women with
cystitis will experience a recurrence.
TB of the Kidney results from hematogenous spread but is relatively rare in developing countries. TB
of the kidney does not manifest until 5-15 years after the primary infection.
UTIs have been well studied in Sweden and other parts of Europe. As 1 in 5 adult women
experience UTI at some point, it is an exceedingly common, clinically apparent, worldwide patient
problem.
Criteria for Referral to
Nephrology
24 hour urine collections for protein are rarely required. An approximation to the
24hour urine protein or albumen secretion is obtained by multiplying the ratio
(in mg/mmol) x10. The need for a nephrology referral in this situation depends
on factors other than simply the presence of haematuria.
Nephrology referral is recommended if there is concurrent:
Evidence of declining GFR by > 10ml/min at any stage within the previous 5
years
or by > 5ml/min within the last one year;
Stage four or five chronic kidney disease, that is a GFR of < 30ml/min;
Significant protienuria ACR less than or equal to 30 mg/mmol or PCR of greater
than or equal to 50 mg/mmol.
Isolated haematuria, that is in the absence of significant protienuria with
hypertension in those aged less than 40.
Visible haematuria coinciding with intercurrent, usually upper respiratory tract
infection. BAUS/RA Guidelines (2008)
Conclusion
Diagnosis was confirmed as recurrent Ta G1 TCC which requires regular Cystoscopy,
possible resection and serial radiological review.
External beam radiotherapy has been shown to be inferior to radical Cystectomy for
the treatment of bladder cancer. The overall 5 year survival after treatment with
external beam radiotherapy is 20-40% compared to 90% 5-year survival after
Cystectomy for organ confined disease.
Devising this algorithm has lead to a logical approach to the diagnosis of frequent
patient presentations encountered in my area of clinical practice. It has further
assisted me to develop a valid approach in differential diagnosis for macroscopic
haematuria by indicating in a structured manner, recurrent encountered decisions in
the diagnostic reasoning pathway