Haematuria

Question 1

What should haematuria in adults be considered a symptom of until proven otherwise?

Answer 1

Malignancy

Question 2

What are the types of visible haematuria?

Answer 2

Macroscopic haematuria, gross haematuria

Question 3

What are the types of non-visible haematuria?

Answer 3

Microscopic haematuria, dipstick positive haemtauria

Question 4

How is non-visible haematuria classed?

Answer 4

Symptomatic and asymptomatic (incidental finding)

Question 5

What are some of the symptoms of non-visible haematuria?

Answer 5

LUTS = hesitancy, frequency, urgency, dysuria
UUTS = renal colic

Question 6

How common is frank haematuria?

Answer 6

40% of all urology referrals = 40% caused by significant abnormalities, 20% caused by malignancy

Question 7

What is the aetiology of microscopic haematuria?

Answer 7

Prevalence = 2.5-13%
Unknown aetiology in 61-77%
Genito-urinary malignancy in 0.43-5%
UUT carcinoma in 0-0.1%

Question 8

What is microscopic haematuria defined as?

Answer 8

Three or more red blood cells per high power field on microscopic evaluation from two of three specimens

Question 9

What are some risk factors for microscopic haematuria?

Answer 9

Smoking, exposure to chemicals or dyes, history of gross haematuria, age >40, history of urological disorders, history of voiding symptoms, recurrent UTIs, analgesic abuse

Question 10

What effect do inflammatory changes have on blood flow?

Answer 10

Increases blood flow to the infected organ

Question 11

What are some common renal infections?

Answer 11

Urethritis, prostatitis, cystitis, ureteritis, pyelonephritis, glomerulonephritis

Question 12

Why do tumours bleed?

Answer 12

Form new vessels
Increased vessel density in tumour
Abnormal vessels = bleed more easily

Question 13

How common is haematuria in patients with renal cell carcinoma?

Answer 13

50-60% present with haematuria

Question 14

What is the Israel triad of renal cell carcinoma symptoms?

Answer 14

Haematuria, pain, mass = occurs in <10%

Question 15

What are some symptoms of urological tumours?

Answer 15

Haematuria (75-85%), loin pain, renal colic, retention of urine, urinary irritative symptoms

Question 16

How may trauma cause haematuria?

Answer 16

Bleeding around kidney (perirenal haematoma) may cause haematuria if the pelvicalyceal system is breeched

Question 17

What causes sport haematuria?

Answer 17

Renal or bladder trauma due to sport (both contact and non-contact) = common

Question 18

What vessel changes occur in sports haematuria?

Answer 18

Vasoconstriction of renal vessels = hypoxic damage to nephrons
Constriction of efferent arteriole = increased filtration pressure
Increased glomerular permeability

Question 19

How common is sports haematuria after long distance running?

Answer 19

Occurs in 24% = resolves in 7 days

Question 20

What kind of haematuria occurs in sports haematuria?

Answer 20

Microscopic in up to 95% = due to red cell haemolysis and rhabdomyolysis in 80%

Question 21

How often does sporting injury cause renal trauma?

Answer 21

30% of renal trauma is due to sporting injuries

Question 22

Why should sports haematuria always be investigated?

Answer 22

Due to risk of underlying urinary tract injury and other incidental findings

Question 23

What is loin pain haematuria syndrome?

Answer 23

Periods of severe unilateral pain that radiates to abdominal area, medial thigh or groin = lasts for hours or is constant

Question 24

What are some other symptoms of loin pain haematuria syndrome?

Answer 24

Dysuria, vomiting, low grade fever = not associated with UTI

Question 25

What is loin pain haematuria syndrome associated with?

Answer 25

Disease of the peripheral arteries

Question 26

When does decompression haematuria occur?

Answer 26

After catheterisation for chronic urinary retention = usually transient and mild, but can be massive and need transfusion

Question 27

What causes decompression haematuria?

Answer 27

Sudden drop in pressure in the damaged bladder

Question 28

What are important aspects of the history to cover in a patient with haematuria?

Answer 28

Gynaecological and surgical histories, pneumaturia, faecaluria, PV bleeding, abdominal/loin pain, blood thinners or bleeding disorders

Question 29

What are some causes of spurious contamination that may make urine red?

Answer 29

Menstrual blood Food = beetroot, blackberries, rhubarb Myoglobin in urine Drugs and toxins (lead, mercury)

Question 30

What are some causes of myoglobin in urine?

Answer 30

Rhabdomyolysis, McArdle syndrome, Bywater's syndrome

Question 31

What are some drugs that can turn urine red?

Answer 31

Doxyrubicine, chloroquine, rifampicin, nitrofurantoin

Question 32

How common is haematuria in healthy children?

Answer 32

Macroscopic haematuria occurs in 3-5% of healthy children

Question 33

What causes red diaper syndrome?

Answer 33

Serratia marcescens infection

Question 34

What are some common causes of haematuria in children?

Answer 34

UTI, trauma, perineal irritation

Question 35

What are some rarer causes of haematuria in children?

Answer 35

Sickle cell disease, nephrolithiasis, glomerulonephritis, malignancy, urologic abnormalities, coagulopathies, drug-induced cystitis

Question 36

What are some features of Wilm's tumour?

Answer 36

Most common malignancy in patients <15 years old 70-80 cases each year in UK 90% survival rate

Question 37

What are the symptoms of Wilm's tumour?

Answer 37

Frank haematuria = 20% | Fever, abdominal mass, hypertension, malaise

Question 38

What are some factors to consider as to why a patient has haematuria?

Answer 38

Trauma, age, gender, nature of haematuria, addiction, occupation, country of residence, urological history, family history of malignancy, history of bleeding disorders, concomitant treatment, recent UTI symptoms

Question 39

What are some symptoms of a UTI?

Answer 39

Loin pain, frequency, urgency, dysuria, feeling feverish, sweating, shivery

Question 40

What is the strongest risk factor for developing urothelial cancer?

Answer 40

Smoking

Question 41

What occupations are associated with an increased risk of developing urothelial cancer?

Answer 41

Autoworkers, painters, truck drivers, leather workers, metal workers, dry cleaners, dental technicians, barbers, beauticians, hair dressers, plumbers

Question 42

What features of the timing of a patient's haematuria should you ask about?

Answer 42

Initial, terminal, total

Question 43

What signs indicate upper urinary tract haematuria?

Answer 43

Veriform clots and flank pain

Question 44

What are some features of the examination of a patient with haematuria?

Answer 44

Look for bruising/swelling of loin, abdomen, scrotum or perineum Palpate for tenderness or mass of kidney PR examination for prostate

Question 45

What investigations can be done for haematuria?

Answer 45

Urinalysis, culture and sensitivity, USS, CT, MRI, cystoscopy, ureterorenoscopy Urogram = IV, CT, MRI

Question 46

What patients should be urgently referred on the suspected cancer pathway?

Answer 46

All patients >45 with visible haematuria | All patients >60 with symptomatic non-visible haematuria

Question 47

What patients should be referred to urology?

Answer 47

All patients with visible haematuria or symptomatic non-visible haematuria All patients aged >= 40 with asymptomatic non-visible haematuria

Question 48

When should patients be referred to nephrology?

Answer 48

Evidence of declining renal function Chronic kidney disease Significant proteinuria Isolated haematuria with hypertension >= 40 years old Visible haematuria coinciding with intercurrent infection