Hematuria and obstructive uropathy
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This document discusses hematuria (blood in the urine) and obstructive uropathy (blockage of urine flow in the urinary tract). It covers evaluating hematuria through urinalysis, imaging tests, and cystoscopy. Common causes of hematuria include infections, stones, tumors, and glomerulonephritis. Obstructive uropathy can be congenital or acquired and cause changes to the urethra, bladder, ureters, and kidneys over time. Relieving the obstruction through surgery, stents, or nephrostomy is the main treatment approach.
Hematuria and obstructive uropathy
- 1. Hematuria & obstructive Uropathy
- 2. Hematuria
- 3. Physical Examination of Urinean evaluation of color, turbidity, specific gravity and osmolality, and pH.
- 5. Urinary dipstickMost common screening test for hematuria
- 6. The reagent strip that detects blood utilizes hydrogen peroxide, which catalyzes a chemical reaction between hemoglobin (or myoglobin) and the chromogentetramethylbenzidine
- 7. Different shades of blue-green are produced according to the concentration of hemoglobin in the urine
- 9. Centrifuged urineIn hemoglobinuria, the supernatant will be pink. This is because free hemoglobin in the serum binds to haptoglobin, which is water insoluble and has a high molecular weight. This complex remains in the serum, causing a pink color. Free hemoglobin will appear in the urine only when all of the haptoglobin-binding sites have been saturated.
- 10. Centrifuged urineIn myoglobinuria, the myoglobin released from muscle is of low molecular weight and water soluble. It does not bind to haptoglobin and is therefore excreted immediately into the urine. Therefore, in myoglobinuria the serum remains clear.
- 11. Quantity of HematuriaMicroscopic Hematuria : seen only under microscopeGross Hematuria : visible, urine is pink, cola, red5 times the number of life-threatening conditions when compared with patients with microscopic hematuria.
- 12. How to evaluate hematuria?By asking questionIs the hematuria gross or microscopic?
- 13. At what time during urination does the hematuria occur (beginning or end of stream or during entire stream)?
- 14. Is the hematuria associated with pain?
- 15. Is the patient passing clots?
- 16. If the patient is passing clots, do the clots have a specific shape? Timing of HematuriaFrequently indicating the site of origin asInitial hematuria from urethra, least common, usually secondary to inflammationTerminal hematuria secondary to inflammation at bladder neck or prostatic urethraTotal hematuria from bladder or upper tract, most common
- 17. Total HematuriaTerminal HematuriaInitial Hematuria
- 20. inflammation of the bladder or prostate.
- 23. Burning pain in the penis or urethral opening in women
- 25. Pain in the perineum associated with dysuria, fever, and rigors
- 27. Constant dull flank pain
- 28. sign of advanced RCCClassification : PainPainless (Gross) HematuriaWith Age > 50 years ( Mostly Men ) is HALLMARK for bladder cancer.
- 29. ClotsThe presence of clots usually indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.
- 30. Shape of ClotsAmorphous clots : bladder or prostatic urethral origin
- 31. Vermiform (wormlike) clots, particularly if associated with flank pain : the upper urinary tract : ureterDuration of HematuriaTransient HematuriaBenign & without any obvious etiology in 39%of young adults 8-9% of adults >50y/o – malignancyPersistent HematuriaDefined as three positive urinalyses, based on a test strip and microscopic examination, over a 2- to 3- week periodMicroscopic – 5% malignancyMacroscopic – 20% malignancy
- 34. Trauma
- 35. Neoplasm
- 38. Metabolic
- 39. Stone
- 40. Miscellaneous
- 41. DrugMost common cause of hematuria 0-20 yr Acute glomerulonephritis Acute UTI Congenital UT anomalies with obstruction 20-40 yr Acute UTI Stones Bladder tumors40-60 yr (men) Bladder tumors Acute UTI Stones40-60 yr (women) Acute UTI Stones Bladder tumors60 yr (men) BPH Bladder tumors Acute UTI60 yr (women) Bladder Tumor Acute UTI
- 44. Glomerular HematuriaBegin with a thorough history
- 45. IgA nephropathy (Berger's disease)
- 46. Familial nephritis or Alport's syndrome
- 49. PoststreptococcalglomerulonephritisNon-glomerular Hematuria Non-glomerular hematuria or essential hematuria includes primarily urologic rather than nephrologic diseasesCommon causes of essential hematuria include urologic tumors, stones, and UTIs
- 50. Non-glomerular Hematuria Characterized by circular erythrocytes and the absence of erythrocyte casts
- 51. An algorithm for the evaluation of nonglomerular hematuria
- 52. Work –up : Laboratory StudiesUrinalysis
- 54. BUN/serum creatinine: Elevated levels of BUN and creatinine suggest significant renal disease as the cause of hematuria
- 55. Hematologic and coagulation studies: CBC counts , Platelet counts
- 56. Urine calcium : A calcium excretion of more than 4 mg/kg/d or a urine calcium-creatinine ratio of more than 0.21 are considered abnormal.
- 58. Urine culture : A midstream or clean-catch specimen of urine should be obtained for culture sensitivity whenever a urinary tract infection is suspected.Work-up : Imaging StudiesRenal and bladder ultrasonography
- 59. Urinary tract anomalies, such as hydronephrosis, hydroureter, nephrocalcinosis, tumor, and urolithiasis, are readily revealed with ultrasonography
- 60. Compared with other imaging studies, sonography is rapid, noninvasive, readily available, and devoid of exposure to radiation
- 61. In individuals with severe obesity, a more accurate definition of renal structures and surrounding organs can be achieved using only CT scanningWork-up : Imaging StudiesOther imaging studies
- 62. A spiral CT scan is particularly useful in the detection of urolithiasis, Wilms tumor, and polycystic kidney disease
- 63. Voiding cystourethrograms are valuable in detecting urethral and bladder abnormalities that may result in hematuria (eg, cystitis)
- 64. Radionuclide studies can be helpful in the evaluation of obstructing calculi Microscopy of urinary sediment. Typical appearance in non-glomerular hematuria: RBCs are uniform in size and shape but show two populations of cells because a small number have lost their hemoglobin pigmentMicroscopy of urinary sediment. A cast containing numerous erythrocytes, indicating glomerulonephritis
- 65. Persistent microscopic HematuriaEvidence of glomerular diseaseYesNoRenal parenchymal disease evaluationUrologic evaluationRenal BiopsyRisk of urologic malignancyAge > 40 years
- 66. Heavy smoking
- 67. Pelvic radiation
- 68. Exposure: dyes benzene
- 69. Chronic urological tract infection- Urine 24-hr, calcium- Imaging- Cystoscopy + CytologyNo- Imaging- Cystoscopy + CytologyYes
- 71. DefinitionFunctional or anatomic obstruction of urinary flow at any level of the urinary tract
- 72. ClassificationObstructive uropathy may be classified in tocongenital/acquired
- 73. Benign/malignant
- 74. Partial/complete
- 79. ureterovesical junction obstructionureteropelvic junction obstruction (various causes)neurologic deficitesAcquiredurethral strictures inflammatory or traumaticbladder outlet obstruction
- 80. vesical tumor
- 83. ureteral or pelvic stones, strictures and tumorHistory taking: Present IllnessSymptomsLower urinary tract (urethra and bladder) -hesitancy -lessened force and size of the stream -terminal dribbling
- 84. History taking: Present Illness2.Upper urinary tract ( ureter and kidney) -pain in the flank radiating along the course of the ureter -gross hematuria (from stone) -GI symptoms -fever with chills - may be asymptomatic
- 85. Physical Exam: Present IllnessSignsLower urinary tract -Palpation of urethra -Vesical distention
- 86. Physical Exam: Present Illness2. Upper urinary tract -Palpation of kidney
- 87. Pathogenesis (pathophysiology) The changes in the various segments in the urinary tract, depending on the obstructive severity and duration1. Urethral changes: dilatation, diverticulum
- 88. 2. Bladder changes: trabeculation , trigone hypertrophy , diverticulum
- 89. 3. Ureteral changes: distention, dilatation and hydroureter
- 90. 4. Pelvicalyceal changes: first shows evidence of hyperactivity and hypertrophy and then progressive dilatation and followed by flattening of the papillae and finally clubbing of the minor calyces. 5. Renal Parenchymal Changes : compression, ischemic atrophy.
- 92. Clinical findings1.Symptoms and signs: infravesical obstruction :difficulty of voiding,weak stream ,diminished flow rate,terminal dribbling,burning ,frequency.Supravesical obstruction :renal pain or renal colic,if gradually--asymptomatic or enlarged kidney
- 93. Clinical findings2.Laboratory findingsUrinalysisBUN CreatinineImpaired kidney function elevated blood urea nitrogen and serum creatinine
- 94. Clinical findings3.X-Ray findings , IVP, Cystoscopy , Retrograde pyelographylocalizing the site of obstructiondemonstrate the extent of the obstructed segmentanatomic changes functional changes
- 95. Clinical findings4.Special Examination Instrumental calibration of sites of obstruction is also valuableradioisotope renographyultrasonic examination shows hydronephrosis and residual urine Urine flow rateCT
- 96. Treatment1. Relief of obstruction -BPH or obstructing bladder tumors require surgical removal -impacted stones must be removed
- 97. Treatment2.urethral stricture can be dilatated or urethrotomy or urethroplasty
- 98. Treatment3.Percutaneous nephrostomy or double –J stent4.GFR< 10% : nephrectomy
- 99. Thank You