Haematuria: overview

I had an OSCE station on microscopic haematuria. I didn't really know how to approach, hence, this post on some key facts and checkpoints. Most of this is from John Murtagh's text book and some Australian guidelines.

Key points:

1. Macroscopic haematuria is always abnormal except in menstruating women.

2. Joggers and athletes engaged in very vigorous exercise can develop transient microscopic haematuria.

3. Microscopic (asymptomatic haematuria) can be classified as either:

•  glomerular (from kidney parenchyma): common causes are IgA nephropathy and thin membrane disease
• non-glomerular (urological): the common causes are bladder cancer, benign prostate hyperplasia and urinary calculi

4. 20 % of people with visible haematuria have cancer

5. It is important to exclude kidney damage, so patients should have blood pressure, urinary protein and plasma creatinine levels measured as a baseline and urine red cell cast

6. The possibility of sexually acquired urethritis should be kept in mind

7. Painful haematuria is suggestive of infection, calculi or kidney infarction.

8. Painless haematuria is commonly associated with infection, trauma, tumours or polycystic kidneys

9. A drug history is relevant, especially with anticoagulants and cyclophosphamide. A diet history should also be considered

10. There is no consensus guideline on what imaging test you should request, WA health has developed imaging pathway online and it is free for everyone to access: painless haematuria

11. Key questions (adopted from General Practice by John Murtagh)

• Have you had injury?
• Have you noticed whether the redness is at the start or end of your stream or throughout the stream?
• Bleeding elsewhere?
• Abdominal or loin pain?
• Burning or frequency of your urine?
• Problems with the flow of your urine?
• Have you having large amounts of beetroot, red lollies or berries in your diet?
• Could your problem have been sexually acquired?
• Recent strenuous exercise
• Any kidney problems in the past?

12. Presence of haematuria should not be contributed to anticoagulants or anti platelets, further evaluation is required. (3)

References:

1.  General Practice by John Murtagh
2. WA imaging pathway
3. General practice notebook 

Lower urinary tract symptoms

Key facts:
- Important to determine who much the symptoms are bothering the patient as treatment will be determined by that.

• Examination:
• abdominal examination: looking for a distended bladder
• DRE: looking for an abnormal prostate e.g. hard, nodular, asymmetry
• examination of the penis, checking for a tight phimosis or narrow meatus
• neurological examination of the perineum and lower limbs: looking for neurological condition that could cause a neurogenic bladder
• Investigations
• Urinalysis and urine MCS
• Fasting glucose to exclude diabetes
• UEC 
• PSA after discussing with patient 
• Urinary tract ultrasound 
• other investigations: bladder diary, urinary flow rate and urodynamic study 
• Differential diagnoses of LUTS
• Lower urinary tract obstruction 
• overactive bladder
• bladder irritation 
• polyuria
• neurological causes 
• Treatment option s
• conservative management for patients with mild symptoms 
• Medical therapy 
• alpha blockers: tamsulosin and prazosin. Tamsulosin is better as it has less side effects, doesn't cause erected dysfunction and acts quickly in few days
• 5 aplha reductase inhibitors: finesteride or dustasteride. slow onset (months) and may cause sexual dysfunction
• combination therapy: tamsulosin/dutasteride
• anticholinergics: best avoid 
• Surgical therapy
• TURP 
• Laser ablation, transurethral needle ablation (TUNA), thermotherapy or open operation

Reference:

- Check program 2012 October

Approach to urinary disorders

Approach to Dysuria

Probability diagnosis 

• UTI esp. cystitis 
• Urethritis 
• Urethral syndrome 
• Vaginitis

Serious disorders not to be missed

• Neoplasia
• Bladder
• Prostate
• Urethra
• Severe infection 
• gonorrhoea
• NSU
• Genital herpes
• Reactive arthritis
• Calculi (e.g. bladder)

Pitfalls 

• Menopause syndrome
• Prostatitis
• Foreign bodies in LUT
• Acidic urine 
• Acute fever
• Interstitial cystitis
• Urethral caruncle/diverticuli
• Vaginal prolapse
• Obstruction 
• benign prostatic hyperplasia
• urethral stricture
• phimosis 
• meatal stenosis 

Testicular Torsion

Condition

• Testicular Torsion

History

• sudden onset, severe scrotal pain
• Swollen and painful scrotum
• Vomiting and abdominal pain 
• Can occur at any age but more common in neonates and children between the age of 12 - 14

Examination 

• Red, tender, swollen scrotum
• Loss of cremasteric reflex
• High lying testes secondary to twisting of the spermatic cord
• Horizontal lie of the contralateral testes 

Investigation

• Do not order ultrasound to confirm diagnosis in paediatric cases 

Management 

• Urgent referral to hospital for operation 
• Torsion must be corrected within 4-6 hours to prevent gangrene of the testis

References

- DCH:  common surgical problems South 

Visible Haematuria

I have been seeing a 57 M in the last few weeks. He is a new patient to the clinic. He has significant history of ETOH abuse and heavy smoker. Around 2 weeks ago, he came to me with a jar which had his urine in it. There was visible haematuria. I sent him for a renal ultrasound and it was returned normal. I was re-assured by the result until I discussed this with one of the GPs today and did a bit of reading myself.

Some key points about visible haematuria:

1. 20 % of people with haematuria has urological malignancy.
2. Visible haematuria requires urgent urology referral.
3. CT urography is the preferred imaging investigation
4. Women have a poorer outcome in bladder cancer often because of delay in investigations.
5. The following flow chart shows the recommended approach:

6. Do not delay referral because you need to wait for the investgating results

7. Risk factors for bladder malignancies:

References:

Australian Doctor How to treat series Visible haematuria.