SAIMA USMAN

HAEMATURIACommon finding Incidental

DEFINING HAEMATURIA

Visible haematuria Non visible haematuria (dipstick and

microscopic)

Indication for urine dipstik testing

Lower urinary tract symptoms Upper urinary tract symptomsDiagnosis of hypertensionDiabetes(at least annually)Newly detected renal dysfunction(e

GFR<60ml/min)Suspected multisystem disease with possible

renal involvement.

Innocent haematuriaHaemoglobinuriaMyoglobinuriaMenstruationSexual intercourseAcute intermittent porphyriaFood :beet root, black berries, rhubarbDrugs:

nitrofurantoin,senna,rifampicin,phenolphthalein,chloroquine,doxorubicin

Chronic lead or mercury poisoning

HAEMATURIAUTI typically causes non visible transient

haematuria and if simple doesn't require further investigations.

Presence of bacterial peroxidases can cause a false positive dipstick test

Dipstick testing for blood is less sensitive in the urine with high specific gravity and heavy proteinuria

CAUSES OF HAEMATURIAPRE RENAL

CAUSES

Bleeding diathesisAtrial fibrillationInfective

endocarditisScurvy

PurpuraLeukaemiaThrombocytopeniahaemophilia

CAUSES OF HAEMATURIARENAL CAUSESNEPHROLOGICAL

IgA nephropathyGlomerulonephritisPolyarteritis nodosaGood pasture’s

syndromeAcute pyelonephritis

Polycystic kidney disease

Haemolytic uremic syndrome

Alport’s syndrome

Causes of haematuriaUROLOGICAL GENERALIZEDMalignancy Benign tumourTraumaCalculusPKDRenal vasculature

problemsMedullary sponge kidney

Renal toxinsSLE

CAUSES OF HEMATURIAPOST RENAL CAUSES

URETERIC

CalculusCarcinoma Papillomaschistosomiasis

BLADDER/PROSTATICTumourBPHProstatic cancerCalculusCystitisInjury/FBPurpuraSchistosomiasis

CAUSES OF HAEMATURIAURETHRAL

Acute urethritisCalculusInjuryCarcinomaPapillomaUrethral meatal ulcerF.B

Approach to haematuriaThorough history including Urinary symptomsRecent history (trauma/muscle injury/causes

of factitious haematuria/exercise/foreign travel)

Systemic features (fever, weight loss) other symptoms(bleeding,bruising)

Co-morbidityDrug historyOccupationFamily history

EXAMINATION

General

Anaemia , wt. loss , skin colour, bruising/bleeding

Vital signsPulse rate, blood pressure, temp.

CardiovascularSigns of infective endocarditis, murmur

RespiratoryLung signs (rare)

Abdominal

Palpable masses, distended bladder

Rectal examinationProstatic enlargement-BPH/cancer

INVESTIGATING HAEMATURIA

Urine MCS To exclude UTI .Red cell cast indicates glomerulonephritis

Urine albumin:creatinine ratio Perform if proteinuria on dipstick of 1+ or more. 24 hrs protein collection is rarely necessary

Full blood count Anaemia, signs of infection, thrombocytopenia

ESR/PV Raised in infection or malignancy

U&Es For renal function and eGFR

INVESTIGATING HAEMATURIA

Clotting screen Remember that haematuria in those on anti coagulants can occur with normal clotting screen

PSA Not in context of UTI that may give a false high reading. Measure 4-6 weeks later.

Kidney ,Ureter and Bladder X-ray To look for stones

Ultrasound scan To look for abnormalities of the renal tract and the kidneys. USS is as sensitive to hydronephrosis and renal masses as IVU and is more cost effective.

REFERRAL CRITERIAURGENT (2 WEEKS WAIT) REFERRAL (urology)

Visible haematuria (unless GN is suspected)Haematuria with recurrent or persistent UTI in

adult over 40 years Persistent non visible haematuria in adult over 50

years.Abdominal mass identified clinically or on

imaging that is thought to arise from urinary tract.

REFERRAL CRITERIAUROLOGY

All patient with symptomatic non-visible haematuria who don't meet the criteria for urgent referral.

Patient with persistent asymptomatic non-visible haematuria age 40-50 years.

REFERRAL CRITERIANEPHROLOGY

Evidence of decline of eGFR (by >10ml/min in previous 5 years or by >5ml/min in the last year).

Stage 4 or 5 kidney disease.Significant proteinuria (ACR 30 or more or PCR

50 or more).Isolated haematuria with hypertension in those

under 40 years.Visible haematuria coinciding with

intercurrent ,usually upper respiratory, infection.

If no cause establishedAnnual assessment(while haematuria

persists)of BP, eGFR and ACR/PCRRe referral to urology if;

Significant or increasing proteinuria(ACR>30 or PCR>50)

Estimated GFR <30ml/min(Confirmed on at least 2 readings and without an identifiable reversible cause)

Deteriorating eGFR(>5ml/min in 1 year or>10ml/min in 5 years.

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