Evaluation and management of hematuria

Question 1

Characterization of gross hematuria depending on the phase and explain indication

Answer 1

1. Initial–> urethral source 2. Terminal –> Trigone,neck prostate 3. Total hematuria –> Bladder and above

Question 2

causes of pigmenturia mimicking GH:

Answer 2

1. Endogenous sources (Bilirubin, myoglobin, porphyrins) 2. Food (Beets, rhubarb) 3. Drugs (phenazopyridine) 4. simple dehydration

Question 3

AUA definition of microscopic hematuria

Answer 3

3 or more / HPF

Question 4

causes of false positives for MH, cause of false negative

Answer 4

first void urine and post sexual activity might cause false positive Dilute urine (<308 osm) -> might cause false negative

Question 5

The likelihood of identifying a malignancy has been found to be greater among patients with higher levels of MH _ RBC/HPF, GH, or risk factors for malignancy

Answer 5

>25 rbc/hpf

Question 6

Common Risk Factors for Urinary Tract Malignancy in Patients With Microscopic Hematuria

Answer 6

Question 7

Patients who develop hematuria who are taking anticoagulaton or antiplatelet medications should undergo _____.

Answer 7

patients who develop hematuria (microscopic or gross) who are taking anticoagulation or antiplatelet medications (e.g., warfarin, enoxaparin, heparin, aspirin, clopidogrel, nonsteroidal anti-inflammatory agents) should undergo a complete evaluation in the same manner as patients not taking such medications

Question 8

In women, the ACOGAU society recommend/does not recommend evaluation for asymptomatic MH for patients that has never smoked aged 33-50 who have <25 hpc. What is the rate of Urinary tract for this malignancy for this patients

Answer 8

does not recomment, <0.5%

Question 9

Blue light cystoscopy uses _____ or ____ instillation

AUA recommends for/against using blue-light cystoscopy for evaluation of MH

Answer 9

5-aminolevulinic acid ALA or Hexyl aminolevulinate (HAL)

Against

Question 10

the imaging of choice by the AUA for evaluation of asymptomatic MH

Answer 10

Multiphasic ct urogram

Question 11

36/F patient consulted for Asymptomatic MH,noted no infection, no menstruation,no urologic procedures, what is the next step for workup

Answer 11

Renal function testing, cystoscopy imaging CTU. COncurrent workup for proteinuria and red cell morphology to see if there is nephrological cause.

If negative for the following, the patient may follow-up at least one UA/Micro yearly for at least 2 years. If still with persistent MH, annual must be done. Repeat anatomic evaluation within 3-5 years if clinically indicated

Question 12

patients presenting with GH in the absence of antecedent ___ or____ should be evaluated with a ____ examination, ___ and ____

Answer 12

patients presenting with GH in the absence of antecedent trauma or culture-documented UTI should be evaluated with a urine cytologic examination, cystoscopy, and upper tract imaging, preferably CT urogram.

Question 13

_____________, a member of the ____ family, is the most common virus associated with hemorrhagic cystitis

Answer 13

BK virus, polyomavirus

Question 14

treatment for viral hemorrhagic cystitis is:___

Answer 14

primarily supportive, with hydration, diuresis, and bladder irrigation, although case reports of success with antiviral therapy exist

Question 15

Chemotherapeutic drugs that cause Hemorrhagic cystitis

Bladder toxicity results from renal excretion of the metabolite ___, which is produced by the liver and stimulates bladder mucosal sloughing and subsequent tissue edema/fibrosis

____, which binds to ___ and renders it inert, has been suggested for prophylaxis against cyclophosphamide-induced hemorrhagic cystitis

Answer 15

cyclophosphomide and iphosphamide

Bladder toxicity results from renal excretion of the metabolite acrolein, which is produced by the liver and stimulates bladder mucosal sloughing and subsequent tissue edema/fibrosis

2-Mercaptoethane sulfonate (mesna), which binds to acrolein and renders it inert, has been suggested for prophylaxis against cyclophosphamide-induced hemorrhagic cystitis

Question 16

what is the initial management for HC? next step if initial management for hemorrhagic cystitis is not effective:

Answer 16

Hyperbaric oxygen therapy

Question 17

this agent may be considered for first-line intravesical therapy among patients with hemorrhagic cystitis failing initial supportive measures, particularly among those without renal insufficiency.

Answer 17

Alum, aluminum ammonium sulfate or aluminum potassium sulfate) may be dissolved in sterile water (50 g alum in a 5-L bag of sterile water [1% alum solution]) and then used to irrigate the bladder at a rate of 200 to 300 mL/h.

Question 18

A lysine analogue, aminocaproic acid is a competitive inhibitor of activators of plasminogen, including urokinase, and thus interrupts fibrinolysis and the cascade that perpetuates hemorrhage

Answer 18

aminocaproic acid

Continuous bladder irrigation with 200 mg aminocaproic acid/L of 0.9% normal saline has been described, with irrigation continued for 24 hours after hematuria resolves.

Question 19

mechanism of HBOT

Answer 19

local tissue oxygen tension increases and thus oxygen extraction by tissues increases, thereby diminishing edema and promoting neovascularization, all of which are critical steps in the wound healing process

Question 20

BPH/Prostate Cancer represents the most common cause of prostate-related bleeding and has been cited as the most common cause of GH in men older than ___

Answer 20

BPH represents the most common cause of prostate-related bleeding and has been cited as the most common cause of GH in men older than 60

Question 21

The cause for BPH-related hematuria has been thought to be increased prostatic vascularity resulting from ____ in hyperplastic prostate tissue This noted increase in microvessel density has in turn been linked to higher levels of _____

Answer 21

The cause for BPH-related hematuria has been thought to be increased prostatic vascularity resulting from higher microvessel density in hyperplastic prostate tissue This noted increase in microvessel density has in turn been linked to higher levels of vascular endothelial growth factor (VEGF)

Question 22

Treatment with finasteride is associated with decreased ___, prostate ___ and __

Answer 22

Treatment with finasteride is associated with decreased VEGF expression (Pareek et al., 2003), prostate microvessel density (Pareek et al., 2003), and prostatic blood flow

Question 23

“Nutcracker syndrome” (i.e., renal vein entrapment syndrome) is defined as the compression of the left/right renal vein between the __ and the superior ___

tx for nutcracker syndrome

Answer 23

“Nutcracker syndrome” (i.e., renal vein entrapment syndrome) is defined as the compression of the left renal vein between the abdominal aorta posteriorly and the superior mesenteric artery anteriorly.

Left renal vein transposition, superior mesenteric artery transposition, and nephrectomy have been described as surgical approaches for management of this condition

Question 24

According to AUA guidelines, microhematuria sufficient to trigger a diagnostic evaluation is defined as:

a. a positive chemical test (urine dipstick) showing small, moderate, or large blood on one properly collected specimen.
b. a positive chemical test (urine dipstick) showing small, moderate, or large blood on at least two of three properly collected specimens.
c. a positive chemical test (urine dipstick) showing large blood on one properly collected specimen.
d. urine microscopy showing three or more red blood cells per high-powered field on one properly collected urine specimen.
e. urine microscopy showing three or more RBC/HPF on at least two of three properly collected urine specimens

Answer 24

. d. Urine microscopy showing three or more red blood cells per high-powered field on one properly collected urine specimen. The presence of three of more RBCs/HPF on a single urine microscopy is associated with malignancy in 2.3-5.5% of patients. Chemical tests for hematuria detect the peroxidase activity of erythrocytes using benzidine, and can render false results in the presence of dehydration, myoglobinuria, high doses of vitamin C, improper technique, and other factors. While higher levels of microhematuria (>25 RBCs/HPF) are known to be associated with higher rates of malignancy on evaluation, setting the threshold higher than three RBCs/HPF or requiring more than one positive urinalysis would lead to an unknown number of missed opportunities for diagnosis

Question 25

The likelihood of finding a malignancy in a patient with microhematuria is influenced by all of the following EXCEPT: a. age. b. gender. c. use of anticoagulants. d. tobacco use. e. degree of hematuria.

Answer 25

c. Use of anticoagulants. Increasing age, male gender, and tobacco use are risk factors for urologic cancers and specifically for urothelial carcinoma. In addition, while there is little data to distinguish among thresholds of two, three, four, or five RBCs/HPF, it is clear that a high level of microhematuria (\>25 RBCs/HPF) is associated with a greater likelihood of malignancy. By contrast, patients using anticoagulant medications or antiplatelet medications have a similar risk of malignancy compared to those who do not use these medications. Therefore such patients should be evaluated comparably to those who do not use anticoagulants or anti-platelet agents

Question 26

According to AUA guidelines, the proper initial assessment of a 50- year-old patient with asymptomatic microhematuria includes: a. blood pressure measurement, serum creatinine level, cystoscopy, and computed tomography (CT) urogram. b. urine cytology, cystoscopy, and CT urogram. c. urine cytology, blue-light cystoscopy, and any upper tract imaging. d. urine cytology and renal/bladder ultrasound. e. no evaluation is necessary unless microhematuria is persistent/recurrent or hematuria is visible

Answer 26

a. Blood pressure measurement, serum creatinine level, cystoscopy, and computed tomography (CT) urogram. The AUA suggests that adult patients presenting with asymptomatic microhematuria should undergo evaluation to determine the cause. Blood pressure measurement and serum creatinine level may help identify patients who require concurrent nephrologic workup, and creatinine level also helps determine patient eligibility for contrast imaging. The evaluation of asymptomatic hematuria includes imaging (preferably with CT urogram), and cystoscopy in patients 35 and older and those under 35 with risk factors for malignancy

Question 27

In the evaluation of patients with microhematuria, cystoscopy may be safely avoided if: a. there are no associated symptoms in a patient of any age. b. the patient is under 35 years of age and without symptoms or risk factors for malignancy. c. the patient is taking aspirin or warfarin. d. the cytology is negative. e. the patient has a history of urinary tract infection and hematuria is still present after treatment

Answer 27

b. The patient is under 35 years of age and without symptoms or risk factors for malignancy. The AUA guidelines ( Fig. 16.1 ) call for use of cystoscopy for evaluation of hematuria in all patients 35 years of age and older (Recommendation). The risk of malignancy is very low in persons under 35 years of age, such that the potential benefits of cystoscopy may be outweighed by the very small risks associated with the procedure. Therefore it is an option to omit cystoscopy in patients under the age of 35, provided that the patient does not have risk factors for a urologic malignancy.

Question 28

Patients presenting with gross hematuria in the absence of recent trauma or concurrent infection who are on anticoagulation medications should be evaluated with: a. urinalysis, urine cytology, and cystoscopy only. b. CT urogram, with cystoscopy only if symptomatic. c. no evaluation necessary. d. assessment of anticoagulation status, and evaluation only if supra-therapeutic. e. urine cytology, cystoscopy, CT urogram.

Answer 28

e. Urine cytology, cystoscopy, CT urogram. Given the increased frequency with which clinically significant findings are associated with gross hematuria, the recommended evaluation in this setting is relatively uniform. That is, patients presenting with gross hematuria in the absence of antecedent trauma or culture-documented urinary tract infection should be evaluated with a urine cytology, cystoscopy, and upper tract imaging, preferably CT urogram. Importantly, patients who develop hematuria who are on anticoagulation medications should undergo a complete evaluation in the same manner as patients not taking such medications, as the prevalence of hematuria, as well as the likelihood of finding genitourinary cancers, among patients with hematuria on anticoagulation has been reported to be no different from patients not taking such medications.

Question 29

The metabolite of oxazaphosphorine chemotherapeutic agents which is responsible for hemorrhagic cystitis is: a. Mesna. b. Acrolein. c. Formalin. d. Gemcitabine. e. Methotrexate.

Answer 29

b

Question 30

Use of intravesical alum for hemorrhagic cystitis should be avoided in patients with: a. a history of malignancy. b. a history of detrusor instability. c. active gross hematuria. d. renal insufficiency. e. vesicoureteral reflux

Answer 30

d. Renal insufficiency. Alum may be considered for first-line intravesical therapy among patients with hemorrhagic cystitis ( Fig. 16.2 ) failing initial supportive measures. However, while cell penetration and therefore overall toxicity of this agent are low, systemic absorption may nevertheless occur and may result in aluminum toxicity, with consequent mental status changes, particularly among patients with renal insufficiency. Meanwhile, prior to intravesical administration of silver nitrate or of formalin, a cystogram should be obtained to evaluate for the presence of vesicoureteral reflux.

Question 31

A 35-year-old man presents with complaint of penile pain and immediate detumescence during intercourse. Physical examination notes blood at the urethral meatus. The next step should be: a. immediate operative exploration. b. CT scan of pelvis. c. retrograde urethrography. d. obtain serum coagulation parameters. e. conservative management with serial examinations.

Answer 31

Retrograde urethrography. The clinical scenario is consistent with an acute penile fracture. Blood at the meatus raises suspicion for concomitant urethral injury that requires investigation by retrograde urethrography prior to planned operative repair. Conservative management poses the risk of untreated urethral and corporal injury that can result in urethral stricture disease and erectile dysfunction. 11. b. Renal angiography.

Question 32

Alum may be used as a first-line intravesical therapy for hemorrhagic cystitis in patients ___ . Formalin is a highly effective form of intravesical therapy for hemorrhagic cystitis. A ____ should be obtained before therapy to ensure no \_\_\_\_

Answer 32

10. Alum may be used as a first-line intravesical therapy for hemorrhagic cystitis in patients without renal dysfunction. 11. Formalin is a highly effective form of intravesical therapy for hemorrhagic cystitis. A cystogram should be obtained before therapy to ensure no vesicoureteral reflux.