Haematuria

Question 1

How common is visible haematuria?

Answer 1

It is common and visible haematuria makes up 50% of urology referrals

Question 2

Serious?

Answer 2

• It can be potentially serious so should perform and ABCDE assessment + appropriate investigations if concerned re haemodynamic stability

Question 3

What should and MUST be excluded in all haematuria patients

Answer 3

MALIGNANCY

• Its cause should be treated as malignancy until proven otherwise

Question 4

What is important to ascertain when investigating non-vis haematuria?

Answer 4

Whether it is symptomatic or incidental finding - symptomatic much more significant but still need to investiagte asymp (3 serial dipsticks)

Question 5

What is important to ascertain when investigating non-vis haematuria?

Answer 5

Whether it is symptomatic or incidental finding - symptomatic much more significant but still need to investiagte asymp (3 serial dipsticks)

Question 6

Non-visible usually benign?

Answer 6

Yes approx 2.5% of population have benign (90% of them have no malignancy - usually UTIs nd that)

Question 7

Transient, non-pathological causes

Answer 7

• UTI (treat and repeat dip to confirm resolution)
• Menstruation
• Vigorous exercise (this normally settles after around 3 days)
• Sexual intercourse
• Spurious causes - red/orange urine, where blood is not present on dipstick
  • drugs: rifampicin, doxorubicin
  • foods: beetroot, rhubarb

Question 8

Kidney-related causes?

Answer 8

• infection
• cancer e.g. renal cell carcinoma / urothelial cell carcinoma
• stones
• Trauma (iatrogenic e.g. catheter, radiotherapy or injury)
• Nephropathy / glomerulonephritis / renal cysts (tends to be kids w proteinuria)
• Kidney stroke / vascular causing infarction and bleeding
• Drugs - Cause tubular necrosis or interstitial nephritis: aminoglycosides, chemotherapy, penicillin, sulphonamides, and NSAIDs

Question 9

Kidney-related causes?

Answer 9

• infection
• cancer e.g. renal cell carcinoma / urothelial cell carcinoma
• stones
• Trauma (iatrogenic e.g. catheter, radiotherapy or injury)
• Nephropathy / glomerulonephritis / renal cysts (tends to be kids w proteinuria)
• Kidney stroke / vascular causing infarction and bleeding
• Drugs - Cause tubular necrosis or interstitial nephritis: aminoglycosides, chemotherapy, penicillin, sulphonamides, and NSAIDs

Question 10

Ureter causes?

Answer 10

Ureters

• Infection
• cancer
• stones
• trauma (iatrogenic e.g. catheter, radiotherapy or injury)

Question 11

Bladder causes?

Answer 11

Bladder

• Infection
• cancer
• stones
• trauma (iatrogenic e.g. catheter, radiotherapy or injury)

Question 12

Prostate causes?

Answer 12

Prostate

• infection (prostatitis)
• cancer
• trauma (iatrogenic e.g. catheter, radiotherapy or injury)
• BPH

Question 13

Urethral causes

Answer 13

Urethra

• infection e.g. chlamydia
• cancer
• trauma (iatrogenic e.g. catheter, radiotherapy or injury)

Question 14

Urethral causes

Answer 14

Urethra

• infection e.g. chlamydia
• cancer
• trauma (iatrogenic e.g. catheter, radiotherapy or injury)

Question 15

Other causes?

Answer 15

bleeding disorders - haemophilias

anticoagulants

Gynae (endometriosis cyclical bleeding mistaken for haematuria)

Question 16

Questions for Hx

Answer 16

Hx
- Any clots in the urine? Colour of urine?
- Timeline - Is the haematuria persistent? How long has it been going on for?
- A general question of ‘have you had a water infection before?’ ‘Do you think it could be it again?’ Would usually open your door to more information.

Full uro symps history, full gynae and sexual

PMHx - smoking, urological issues, dyes,

Question 17

Questions for Hx

Answer 17

Hx
- Any clots in the urine? Colour of urine?
- Timeline - Is the haematuria persistent? How long has it been going on for?
- A general question of ‘have you had a water infection before?’ ‘Do you think it could be it again?’ Would usually open your door to more information.

Full uro symps history, full gynae and sexual

PMHx - smoking, urological issues, dyes, schistosomiasis, recent interventions?

Question 18

Examinations?

Answer 18

ABCDE
DRE (prostate Ca - haematopsermia too)
Abdo exam
look for evidence of retention
?catheter (watch if trauma suspected / seeding of tumour)

Question 19

Bloods

Answer 19

• FBC
• U&Es
• CRP
• Urine protein-creatinine ratio
• eGFR
• Coagulation
• [PSA] (for male)
• Glucose
• HbA1c

Question 20

Orifice test?

Answer 20

• urine dipstick
• Send a urine MC&S

Question 21

Imaging

Answer 21

• CT KUB or US KUB
• Cystoscopy (to rule of malignancy)

Question 22

Treatments

Answer 22

• If unstable then fluids/bloods
• achieve haemostasis
  
  • ?washout / irrigation
    
    • Blood can clot and can cause retention in bladder so catheter inserted and washout done to clear clots
      
      • Is this just a temporary measure? Will clots not reform?
      • How do you permanent stop the bleeding?
• If retention then 3-way catheter to improve flow
• Treat underlying cause

Question 23

Merlot / Rose rule

Answer 23

Generally speaking, if the urine is rosé in colour, then we can just increase the fluid intake and manage conservatively. A merlot colour means it is old blood, and therefore they may be blood clots in the bladder, and fresh red blood means fresh active bleeding.

Question 24

Why catheter help w bleeding?

Answer 24

The management for the latter two would be to insert a 3-way urinary catheter, by inserting a bigger catheter, you have a bigger balloon (20ml), this will act as a pressure point on the bleeding site. This is because most bleeding occurs from the neck of the bladder. Secondly, a 3-way catheter would also allow you to do bladder washout and irrigation, which is very useful in clearing blood clots inside the bladder.