Haematuria For Medical Finals (based On Newcastle University Learning Outcomes)
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Hospital Based Practice – Haematuria. •
Causes. ○ Renal causes. Neoplasia Glomerularnephritis
• Often IgA nephropathy. Tubulointerstitial nephritis Polycystic ovary syndrome Papillary necrosis Pyelonephritis Trauma Extrarenal causes. Calculi Infection • Cystitis • Prostatitis
○
•
Urethritis. Neoplasia. • Bladder • Prostate • Urethra Trauma.
• •
Eg. From catheter.
Investigations. ○ Urine dipstix. False dipstix +ve haematuria can be due to. • Myoglobulinuria ○ Rhabdomyolisis • Beetroot • Porphyria • Alkaptonuria • Rifampicin • Phenindione • Phenolphthalein. ○ Urine MC&S ○ Bloods FBC U&E ESR CRP Clotting ○ Others. AXR/ KUB X – ray Rine cytology Estimation of protienuria Renal ultrasound Renal biopsy.
•
Management. ○ Usually refer first to a urologist, rather than nephrologist. ○ Refer to a nephrologist if. Risk of urothelial cancer is low. Risk of glomerulonephritis is not negligible. • Aged < 40 years
•
○
Raised creatinine
• Hypertension • Proteinuria • Systemic symptoms • Family history of renal disease Not all women with recurrent UTI and haematuria require cytoscopy. Have a good reason for NOT doing cytoscopy.
Renal stones. • Due to crystal aggregates. • Form in collecting duct.
•
My be deposited anywhere from renal pelvis to urethra.
•
Prevalence & incidence. ○ Life time risk of 15% ○ Peak age of onset is 20 – 40 years. ○ Male: Female ratio of 3:1 ○ Types of stone. ○ Calcium oxalate ○ Magnesium aluminium phosphate. Struvite Triple phosphate. ○ Others. Urate Hydroxyapatite Cysteine Brushite Mixed
•
75% 10 – 20%
5% 5% 1%
Type Calcium oxalate
Causative factors Metabolic
Appearance on X – ray Spikey
Calcium phosphate
Idiopathic Metabolic
Radiopaque Smooth
Idiopathic
May be large
Magnesium aluminium phosphate
UTI
Radiopaque Large horny (‘Staghorn’)
Urate
Hyperuricaemia
Radiopaque Smooth Brown
Cystine
Renal tubular defect,
Radiolucent Yellow
Crystalline Semi – opaque
•
•
Clinical pictures. ○ May be asymptomatic. ○ Pain. Kidney stones cause loin pain Ureter stones cause renal colic • Radiates from loin to groin • Nausea • Vomiting • Patient unable to lie still. ○ Compare with peritonitis. Bladder or urethral stone cause pain on passing urine. • Poor urine flow. • Intermittent urine flow. ○ Infection. Can co – exist with stones. Presents with. • Cystitis. ○ Frequency ○ Dysuria
Think about. ○ Diet.
•
Pyelonephritis. ○ Fever ○ Rigors ○ Loin pain ○ Nausea ○ |Vomiting.
•
Pyonephritis. ○ Infected hydronephritis.
Oxalate levels can be increased by. • Chocolate • Tea • Rhubarb
• ○
○
○
Spinach
Time of the year. Increased sunlight in summer increases Vitamin D synthesis, and so calcium and oxalate levels. Occupation. Can they drink freely Is there risk of dehydration Are there any precipitating drugs? Loop diuretics Antacids Acetazolamide
○
Corticosteroids Theophylline Aspirin Thiazide diuretics. Allopurinol Vitamin C & D Indinavir
Predisposing factors. Recurrent UTI. • Magnesium aluminium phosphate stones. Metabolic abnormalities. • Hypercalciuria • Hypercalcaemia • Hyperparathyroidism • Neoplasia • Sarcoidosis • Hyperthyroidism • Addison’s syndrome • Cushing’s syndrome • Lithium • Vitamin D excess
•
Hyperuricosuria.
•
○
Uraemia. ○ Alone ○ With gout. • Hyperoxaluria • Cystinuria • Renal tubular acidosis Urinary tract abnormalities.
•
Pelviureteric junction obstruction
•
Hydronephrosis
•
Calyceal diverticulum
• •
Horse shoe kidney Ureterocele
• • •
Vesicoureteric reflux Medullary sponge kidney.
Family history. Increases risk of stones threefold. Specifically.
• •
○
Ureteral stricture
X – linked nephrolithiasis
Dent’s disease ○ Proteinuria ○ Hypercalciuria ○ Nephrocalcinosis Infection above the stone. Fever Loin tenderness
•
Investigations. ○ Bloods.
○
○
Urine.
Pyuria Infection requires urgent intervention.
FBC U&E Calcium Phosphate Glucose Bicarbonate Urate. Dipstix MSU 24 hour urine for. • Calcium • Oxalate • Urate • Citrate • Sodium • Creatinine • Stone biochemistry.
Imaging. KUB X – ray.
•
Look along ureters for calcifications.
•
Check transverse processes of vertebral bodies.
• 80% of stone are visible on X – ray Abdominal ultrasound. • Hydronephrosis • Hydroureter CT. • 99% of stone are visible on CT • Superior to IVU in imaging stones. •
Helps exclude differential causes of acute abdomen.` ○ Presentation is similar to ruptured AAA.
•
Management. ○ Prompt analgesia. Diclofenac • IV, IM or PR Morphine + metaclopramide. ○ If not tolerating oral intake. IV fluids. ○ If infection suspected. Cefuroxime. ○ Urgent urological referral. Dealy can result in infection and permanently damaged kidney function. ○
Surgery.
Open surgery is rarely done. Extracorpreal shockwave lithotripsy (ESWL). • Using US waves to shatter the stone.
•
Ureteric stones < 1 cm are suitable for ESWL.
• Renal stones respond well to ESW|L if < 2 cm diameter Percutaneous nephrostomy. • Surgically relieves obstruction. Ureteroscopy + laser.
•
○
Ureteric stones > 1 cm Percutaneous nephrolithotomy. (PCNL).
•
Laproscopic removal of stones.
•
Renal stones > 2 cm diameter
Non – acute management. Between attacks, stones can be managed conservatively. Increase fluid intake. Sieve urine to catch stone. • Send stone for biochemical analysis. Most stones pass within 48 hours. • Some take up to a month. Stones < 5 mm diameter will pass spontaneously 90% of the time. • Treat conservatively. • Monitor progress on serial AXR every 1 – 2 weeks.
•
Prevention. ○ Drink plenty of fluids, especially in warm weather. Aim for 2 – 3 litres of colourless urine per day. ○ Normal calcium diet. Low intake increases oxalate excretion.
○
○
○
○
○
Calcium stones. Thiazide diuretic Eg. Bendroflumethazide. Oxalate stones. Reduce oxalate intake. • Tea • Choloclate • Nuts • Strawberries • Rhubarb • Spinach • Beans • Beetroot Pyridoxine may help. Magnesium aluminium phosphate stones. Treast infection promptly. Urate stones. Allopurinol Urine alkalisation.
• • •
Urate is soluble when pH > 6.
•
Chelates cystein.
•
Give with pyridoxine to prevent Vitamin B6 deficiency.
Eg. Potassium citrate.
Eg. Sodium bircabonate. Cystine stones. Vigorous hydration to keep urine output > 3 L/day. Urinary alkalisation. D – penicillamine.
Causes. ○ Renal causes. Neoplasia Glomerularnephritis
• Often IgA nephropathy. Tubulointerstitial nephritis Polycystic ovary syndrome Papillary necrosis Pyelonephritis Trauma Extrarenal causes. Calculi Infection • Cystitis • Prostatitis
○
•
Urethritis. Neoplasia. • Bladder • Prostate • Urethra Trauma.
• •
Eg. From catheter.
Investigations. ○ Urine dipstix. False dipstix +ve haematuria can be due to. • Myoglobulinuria ○ Rhabdomyolisis • Beetroot • Porphyria • Alkaptonuria • Rifampicin • Phenindione • Phenolphthalein. ○ Urine MC&S ○ Bloods FBC U&E ESR CRP Clotting ○ Others. AXR/ KUB X – ray Rine cytology Estimation of protienuria Renal ultrasound Renal biopsy.
•
Management. ○ Usually refer first to a urologist, rather than nephrologist. ○ Refer to a nephrologist if. Risk of urothelial cancer is low. Risk of glomerulonephritis is not negligible. • Aged < 40 years
•
○
Raised creatinine
• Hypertension • Proteinuria • Systemic symptoms • Family history of renal disease Not all women with recurrent UTI and haematuria require cytoscopy. Have a good reason for NOT doing cytoscopy.
Renal stones. • Due to crystal aggregates. • Form in collecting duct.
•
My be deposited anywhere from renal pelvis to urethra.
•
Prevalence & incidence. ○ Life time risk of 15% ○ Peak age of onset is 20 – 40 years. ○ Male: Female ratio of 3:1 ○ Types of stone. ○ Calcium oxalate ○ Magnesium aluminium phosphate. Struvite Triple phosphate. ○ Others. Urate Hydroxyapatite Cysteine Brushite Mixed
•
75% 10 – 20%
5% 5% 1%
Type Calcium oxalate
Causative factors Metabolic
Appearance on X – ray Spikey
Calcium phosphate
Idiopathic Metabolic
Radiopaque Smooth
Idiopathic
May be large
Magnesium aluminium phosphate
UTI
Radiopaque Large horny (‘Staghorn’)
Urate
Hyperuricaemia
Radiopaque Smooth Brown
Cystine
Renal tubular defect,
Radiolucent Yellow
Crystalline Semi – opaque
•
•
Clinical pictures. ○ May be asymptomatic. ○ Pain. Kidney stones cause loin pain Ureter stones cause renal colic • Radiates from loin to groin • Nausea • Vomiting • Patient unable to lie still. ○ Compare with peritonitis. Bladder or urethral stone cause pain on passing urine. • Poor urine flow. • Intermittent urine flow. ○ Infection. Can co – exist with stones. Presents with. • Cystitis. ○ Frequency ○ Dysuria
Think about. ○ Diet.
•
Pyelonephritis. ○ Fever ○ Rigors ○ Loin pain ○ Nausea ○ |Vomiting.
•
Pyonephritis. ○ Infected hydronephritis.
Oxalate levels can be increased by. • Chocolate • Tea • Rhubarb
• ○
○
○
Spinach
Time of the year. Increased sunlight in summer increases Vitamin D synthesis, and so calcium and oxalate levels. Occupation. Can they drink freely Is there risk of dehydration Are there any precipitating drugs? Loop diuretics Antacids Acetazolamide
○
Corticosteroids Theophylline Aspirin Thiazide diuretics. Allopurinol Vitamin C & D Indinavir
Predisposing factors. Recurrent UTI. • Magnesium aluminium phosphate stones. Metabolic abnormalities. • Hypercalciuria • Hypercalcaemia • Hyperparathyroidism • Neoplasia • Sarcoidosis • Hyperthyroidism • Addison’s syndrome • Cushing’s syndrome • Lithium • Vitamin D excess
•
Hyperuricosuria.
•
○
Uraemia. ○ Alone ○ With gout. • Hyperoxaluria • Cystinuria • Renal tubular acidosis Urinary tract abnormalities.
•
Pelviureteric junction obstruction
•
Hydronephrosis
•
Calyceal diverticulum
• •
Horse shoe kidney Ureterocele
• • •
Vesicoureteric reflux Medullary sponge kidney.
Family history. Increases risk of stones threefold. Specifically.
• •
○
Ureteral stricture
X – linked nephrolithiasis
Dent’s disease ○ Proteinuria ○ Hypercalciuria ○ Nephrocalcinosis Infection above the stone. Fever Loin tenderness
•
Investigations. ○ Bloods.
○
○
Urine.
Pyuria Infection requires urgent intervention.
FBC U&E Calcium Phosphate Glucose Bicarbonate Urate. Dipstix MSU 24 hour urine for. • Calcium • Oxalate • Urate • Citrate • Sodium • Creatinine • Stone biochemistry.
Imaging. KUB X – ray.
•
Look along ureters for calcifications.
•
Check transverse processes of vertebral bodies.
• 80% of stone are visible on X – ray Abdominal ultrasound. • Hydronephrosis • Hydroureter CT. • 99% of stone are visible on CT • Superior to IVU in imaging stones. •
Helps exclude differential causes of acute abdomen.` ○ Presentation is similar to ruptured AAA.
•
Management. ○ Prompt analgesia. Diclofenac • IV, IM or PR Morphine + metaclopramide. ○ If not tolerating oral intake. IV fluids. ○ If infection suspected. Cefuroxime. ○ Urgent urological referral. Dealy can result in infection and permanently damaged kidney function. ○
Surgery.
Open surgery is rarely done. Extracorpreal shockwave lithotripsy (ESWL). • Using US waves to shatter the stone.
•
Ureteric stones < 1 cm are suitable for ESWL.
• Renal stones respond well to ESW|L if < 2 cm diameter Percutaneous nephrostomy. • Surgically relieves obstruction. Ureteroscopy + laser.
•
○
Ureteric stones > 1 cm Percutaneous nephrolithotomy. (PCNL).
•
Laproscopic removal of stones.
•
Renal stones > 2 cm diameter
Non – acute management. Between attacks, stones can be managed conservatively. Increase fluid intake. Sieve urine to catch stone. • Send stone for biochemical analysis. Most stones pass within 48 hours. • Some take up to a month. Stones < 5 mm diameter will pass spontaneously 90% of the time. • Treat conservatively. • Monitor progress on serial AXR every 1 – 2 weeks.
•
Prevention. ○ Drink plenty of fluids, especially in warm weather. Aim for 2 – 3 litres of colourless urine per day. ○ Normal calcium diet. Low intake increases oxalate excretion.
○
○
○
○
○
Calcium stones. Thiazide diuretic Eg. Bendroflumethazide. Oxalate stones. Reduce oxalate intake. • Tea • Choloclate • Nuts • Strawberries • Rhubarb • Spinach • Beans • Beetroot Pyridoxine may help. Magnesium aluminium phosphate stones. Treast infection promptly. Urate stones. Allopurinol Urine alkalisation.
• • •
Urate is soluble when pH > 6.
•
Chelates cystein.
•
Give with pyridoxine to prevent Vitamin B6 deficiency.
Eg. Potassium citrate.
Eg. Sodium bircabonate. Cystine stones. Vigorous hydration to keep urine output > 3 L/day. Urinary alkalisation. D – penicillamine.
