diagnosis and treatment of hematuria rainy umbas department of urology “cipto mangunkusumo”...
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DIAGNOSIS AND TREATMENT OF HEMATURIA
Rainy UmbasDepartment of Urology
“Cipto Mangunkusumo” Hospital / Faculty of MedicineUniversity of Indonesia
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What is hematuria?
What causes hematuria?
Is hematuria always a bad thing?
What tests are needed?
What is the treatment?
What if no cause is found?
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What is hematuria?
• Hematuria means the appearance of blood in the urine.
• It could be visible (= macroscopic hematuria)
• Or microscopic hematuria, it means there were three or more red blood cells per high-power microscopic field in urinary sediment
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What causes hematuria?
• Macroscopic hematuria : about one in three cases are associated with malignancy somewhere in the urinary tract (www.renux.ed.ac.uk)
• Microscopic hematuria : maybe associated with urologic malignancy in up to 10% of adults (Khadra MH et al, J Urol 2000; 163: 524-527)
• Glomerular cause• Non-glomerular cause: - renal
- extra-renal
- other causes
(McDonald MM et al, Am Fam Physician 2006)
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What causes hematuria?
Glomerular cause:
Alport’ syndrome Membranoprliverative glomerulonephritis
Fabry’s disease Mesangial proliverative glomerulonephritis
Goodpasture’s syndrome Nail-patella syndrome
Hemolytic uremia Other postinfectious glomerulonephritis
Henoch-Schönlein purpura Thin basement nephropathy (benign familial hematuria)
Immunoglobulin A nephropathy Wegener’s granulomatosis
Lupus nephritis Poststreptococcal glomerulonephritis
(McDonald MM et al, Am Fam Physician 2006)
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What causes hematuria?
Medications that can cause hematuria:
Aminoglycosides Cyclophosphamide (Cytoxan)
Amitriptyline Diuretics
Analgesics Oral contraseptives
Anticonvulsants Penicillins (extended spectrum)
Aspirin Quinine
Busulfan Vincristine (Oncovin)
Chlorpromazine Warfarin (Coumadin)
(McDonald MM et al, Am Fam Physician 2006)
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What causes hematuria?
Non-glomerular cause:
Renal (tubulointerstitial)• Acute tubular necrosis• Familial
- hereditary nephritis
- medullary cystic disease
- multicystic kidney disease
- polycystic kidney disease• Infection: pyelonephritis, tuberculosis, schistomiasis
(McDonald MM et al, Am Fam Physician 2006)
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What causes hematuria?
Non-glomerular cause
Renal (con’t):
• Interstitial nephritis
- drug induced
- infection: syphylis, toxoplasmosis, viral
- systemic disease: sarcoidosis, lymphoma• Loin pain-hematuria syndrome• Metabolic
- hypercalciuria
- hyperuricosuria (McDonald MM et al, Am Fam Physician 2006)
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What causes hematuria?
Non-glomerular cause
Renal (con’t):
• Renal cell carcinoma• Solitary renal cyst• Vascular disease
- arteriovenous malformation
- malignant hypertension
- renal artery embolism/thrombosis
- renal venous thrombosis
- sicle cell disease(McDonald MM et al, Am Fam Physician 2006)
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What causes hematuria?
Non-glomerular cause
Extra-renal:
BPH
Calculi
Coagulopathy related: warfarin, heparin, secondary to systemic disease
Congenital abnormalities
Endometriosis
Factitious
Foreign bodies
Infection: prostate, epididymis, urethra, bladder
(McDonald MM et al, Am Fam Physician 2006)
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Hematuria
Stone or BPH as a cause for hematuria
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What causes hematuria?
Non-glomerular cause
Extra-renal (con’t):
Inflammation: drug or radiation induced
Perineal irritation
Posterior urethral valves
Strictures
TCC of ureter, bladder
Trauma: catheterization, blunt trauma
Tumor
(McDonald MM et al, Am Fam Physician 2006)
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Hematuria
Malignancy of kidney/collecting system, ureter, bladder, prostate, and urethra
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What causes hematuria?
Non-glomerular cause
Other causes:
• Exercise hematuria
Myoglobinuria due to strenuous exercise, associated with muscle pain and tenderness
• Menstrual contamination
• Sexual intercourse
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Hematuria
Strenuous exercise can cause blood in urine ! ! !
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CLINICAL PICTURE OF HEMATURIA
Initial hematuriaEntirely hematuria (total)Terminal hematuria
(Courtesy of Prof. Dr. Djoko Rahardjo)
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THE SOURCE OF THE BLEEDING
Penile or bulbous urethraThe flow of urine initials bleed and
afterwards “wash clear”Pathology : inflammation, stone,
malignancy
Initial hematuria possible source of bleeding :
(Courtesy of Prof. Dr. Djoko Rahardjo)
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THE SOURCE OF BLEEDING
Source : higher than bladder neck
The blood mixed with urine, due to:
© Malignancy© Stone© Infection including TB
Entirely Hematuria
(Courtesy of Prof. Dr. Djoko Rahardjo)
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THE SOURCE OF BLEEDING
• Prostatic urethra
• Bladder neck due to “snapping shut”
Terminal Hematuria
(Courtesy of Prof. Dr. Djoko Rahardjo)
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Is hematuria always a bad thing?
It may not be important if any of the following can explain it :
• Hematuria during a menstrual period• When it occurs only during a urinary infection• Some medicines or foods can coor the urine
red. This is not the same as passing blood• When it only occurs following strenuous
exercise
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What test are needed?
First of all is to prove that the red urine is hematuria: urine sediment or strip test
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What tests are needed?
• Physical exam incl. blood pressure
• Confirm with urine microscopic exam if striptest / dipstick was positive.
Strip test / dipstick cannot distinguish among myoglobin, hemoglobin, and red blood cells
• Urine test:
- presence of infection
- proteinuria, red cell casts or dysmorphic red blood cells (together with increased creatinine) suggestive of glomerular cause referred to nephrologist
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What tests are needed?
• Urine cytology
The sensitivity of urine cytology is highest for detection of high-grade lesions in the bladder and carcinoma in situ
Urine cytology studies alone may provide sufficient evaluation of the lower urinary tract in certain low-risk patients
• Urine PCR for TB / acid-fast bacilli staining
Consider for referral to urologist for further evaluation
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What tests are needed?
• Imaging: - Ultrasonography
- KUB & IVU or CT Scan
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What tests are needed?
Patients > 40 years old, those with posotive or atypical cytology, or any patient with the presence of any of the following risk factors:
- smoking history
- occupational exposure to chemicals or dyes
- history of irritative voiding symptoms
- analgesic abuse with phenacetin
- history of pelvic irradiation, or cyclophosphamide exposure
Should have their lower tract assessed by cystoscopy
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What tests are needed?
Cystoscopy or Uretero-renoscopy
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What is the treatment?
Hematuria has no specific treatment.
One should focus on the underlying condition ! ! !
Underlying cause Treatment
Urinary tract infection Antibiotics
Kidney disease Relieve inflamation and limit further damage
Inherited disorders Vary greatly depend on the disorders
Stone disease Stone removal
BPH Relieve obstruction & irritation
Malignancy Depend on tumor stage
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What if no cause is found?
• If there are no signs of serious disease, follow-up every 6 months, up to 36 months, of the urinalysis, urine cytology, blood test and blood pressure.
• This is especially important for persons > 40 years old who have risk factors for urothelial cancers:
- smoking history
- occupational exposure to benzenes or aromatic amines (e.g. Leather dye, rubber, tire industries)
- or history of urologic neoplasm
This group of patients merit referral to a urologist for cystoscopy
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What if no cause is found?
• Immediate urologic re-evaluation with consideration of cystoscopy, cytology or repeat imaging should be performed in case of:
- gross hematuria
- abnormal urinary cytology
- irritative voiding symptoms without infection
• If none of these occurs within three years, the patient does not require further urologic monitoring
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Conclusions
• Hematuria, especially microscopic, present a challenging clinical scenario for family physicians / general practioners
• All patients should be investigated by urine cytology and urinary tract imaging after excluding non-important causes (menses, infection, exersice ect)
• Referral to urologist for further evaluation and cystoscopy is indicated in patients with positive or atypical cytology, patients > 40 years old, and any patients risk factors
• Patients with suspicious cause of glomerular cause should be referred to nephrologist
• Patients shoulod be followed up to 3 years
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References
• Mayo Clinic.com (www.mayoclinic.com)• Renal unit, Royal Infirmary of Edinburg (
www.renux.ed.ac.uk)• Grossfeld GD et al, Am Fam Physician 2001; 63: 1145-54• Khadra MH et al, J Urol 2000; 163: 524-527• McDonald MM et al, Am Fam Physician 2006; 73: 1748-
54• Wollin T et al, Can Urol Assoc J 2009; 3: 77-80
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Acknowledgements
• Prof. Djoko Rahardjo, MD• Chaidir A. Mochtar, MD, PhD• Rizal Hamid, MD• Mr. Ruhyat Yamani• Ms. Leslie Dolfo Nugroho• Ms. Tri Darani
Department of Urology
“Cipto Mangunkusumo” Hospital /
Faculty of Medicine, University of Indonesia