hematuria and obstructive uropathy
DESCRIPTION
Pramongkutklao college of medicineTRANSCRIPT
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Hematuria & obstructive Uropathy
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Hematuria
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Physical Examination of Urine
an evaluation of color, turbidity, specific gravity and osmolality, and pH.
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Red HematuriaHemoglobinuria/myoglobinuriaAnthrocyanin in beets and blackberriesChronic lead and mercury poisoningPhenolphthalein (in bowel evacuants)Phenothiazines (e.g., Compazine)Rifampin
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Urinary dipstick
Most common screening test for hematuria
The reagent strip that detects blood utilizes hydrogen peroxide, which catalyzes a chemical reaction between hemoglobin (or myoglobin) and the chromogen tetramethylbenzidine
Different shades of blue-green are produced according to the concentration of hemoglobin in the urine
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Centrifuged urine
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Centrifuged urine
• In 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.
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Centrifuged urine
• In 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.
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Quantity of Hematuria
• Microscopic Hematuria : seen only under microscope
• Gross Hematuria : visible, urine is pink, cola, red
• 5 times the number of life-threatening conditions when compared with patients with microscopic hematuria.
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How to evaluate hematuria?
By asking question• Is the hematuria gross or microscopic? • At what time during urination does the
hematuria occur (beginning or end of stream or during entire stream)?
• Is the hematuria associated with pain? • Is the patient passing clots? • If the patient is passing clots, do the clots have a
specific shape?
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Timing of Hematuria
Frequently indicating the site of origin asInitial hematuria
from urethra, least common, usually secondary to inflammation
Terminal hematuriasecondary to inflammation at bladder neck or
prostatic urethra
Total hematuriafrom bladder or upper tract, most common
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Total Hematuria
Initial Hematuria
Terminal Hematuria
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Pain•Painful hematuria▫Painful micturition
▫ inflammation of the bladder or prostate.
▫Colicky groin pain ▫ ureteral calculus.
▫Burning pain in the penis or urethral opening in women ▫ urinary infection.
▫Pain in the perineum associated with dysuria, fever, and rigors ▫ seen in prostatitis.
▫Constant dull flank pain▫ sign of advanced RCC
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Classification : Pain
• Painless (Gross) Hematuria• With Age > 50 years ( Mostly Men ) is HALLMARK for
bladder cancer.
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Clots
• The presence of clots usually indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.
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Shape of Clots
Amorphous clots : bladder or prostatic urethral origin
Vermiform (wormlike) clots, particularly if associated with flank pain : the upper urinary tract : ureter
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Duration of Hematuria
• Transient Hematuria• Benign & without any obvious etiology in 39%of young adults • 8-9% of adults >50y/o – malignancy
• Persistent Hematuria• Defined as three positive urinalyses, based on a test strip and microscopic
examination, over a 2- to 3- week period• Microscopic – 5% malignancy• Macroscopic – 20% malignancy
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Causes of Hematuria
• Congenital/inherited• PCKD, Hematologic abnormalities
• Trauma• Neoplasm
• Benign or malignant
• Infection/Inflammation• Metabolic
• Stone
• Miscellaneous• Drug
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Most common cause of hematuria 0-20 YR ACUTE GLOMERULONEPHRITIS
ACUTE UTICONGENITAL UT ANOMALIES WITH OBSTRUCTION
20-40 YR ACUTE UTISTONESBLADDER TUMORS
40-60 YR (MEN) BLADDER TUMORSACUTE UTISTONES
40-60 YR (WOMEN) ACUTE UTISTONESBLADDER TUMORS
60 YR (MEN) BPHBLADDER TUMORSACUTE UTI
60 YR (WOMEN) BLADDER TUMORACUTE UTI
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Hematuria
Nephrologic proteinuria
Glomerular
Dysmorphic
Erythrocytes
Erythrocyte casts
Tubulointerstiti
alCircular
Erythrocytes
UrologicCircular Erythrocytes
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Glomerular Hematuria
•Begin with a thorough history▫IgA nephropathy (Berger's disease) ▫Familial nephritis or Alport's syndrome▫Goodpasture's syndrome▫Systemic Lupus erythematosus▫Poststreptococcal glomerulonephritis
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Non-glomerular Hematuria
– Non-glomerular hematuria or essential hematuria includes primarily urologic rather than nephrologic diseases
– Common causes of essential hematuria include urologic tumors, stones, and UTIs
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Non-glomerular Hematuria
• Characterized by circular erythrocytes and the absence of erythrocyte casts
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An algorithm for the evaluation of nonglomerular hematuria
History
+ Family History of bleeding disorder or bleeding tendency• Abnormal
coagulation studies• Hemophilia• Thrombocyto
penia• Thrombotic
Thrombocytopenia purpura
• Disseminated Intravascular coagulopathy
Serum and 24- hour urine calcium and uric acid• Familial
urolithiasis
+Family History of renal cystic disease• IVU, Renal
ultrasonography• Medullary
sponge kidney• Polycystic
kidney disease
Systemic anticoagulation• PT,PTT with
therapeutic range• IVU renal
Ultrasonography• R/O
urologic abnormality
• PT,PTT above therapeutic range• Stop
coagulant• Consider
IVU Renal ultrasonography
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Work –up : Laboratory StudiesUrinalysisPhase contrast microscopyBUN/serum creatinine: Elevated levels of BUN and creatinine
suggest significant renal disease as the cause of hematuriaHematologic and coagulation studies: CBC counts , Platelet
countsUrine 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.
Serologic testingUrine culture : A midstream or clean-catch specimen of urine
should be obtained for culture sensitivity whenever a urinary tract infection is suspected.
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Work-up : Imaging Studies
•Renal and bladder ultrasonography▫ Urinary tract anomalies, such as hydronephrosis,
hydroureter, nephrocalcinosis, tumor, and urolithiasis, are readily revealed with ultrasonography
▫Compared with other imaging studies, sonography is rapid, noninvasive, readily available, and devoid of exposure to radiation
▫In individuals with severe obesity, a more accurate definition of renal structures and surrounding organs can be achieved using only CT scanning
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Work-up : Imaging Studies
•Other imaging studies ▫A spiral CT scan is particularly useful in the
detection of urolithiasis, Wilms tumor, and polycystic kidney disease
▫Voiding cystourethrograms are valuable in detecting urethral and bladder abnormalities that may result in hematuria (eg, cystitis)
▫Radionuclide studies can be helpful in the evaluation of obstructing calculi
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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 pigment
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Microscopy of urinary sediment. A cast containing numerous erythrocytes, indicating glomerulonephritis
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Advantages Disadvantagesr
IVP Excellent for kidney and ureter
May miss bladder lesion
Cystoscopy Best for bladder Invasive and expensive
Ultrasonogram Excellent for kidney Less sensitive for ureter and bladder
Retrograde pyelogram Best for ureter Invasive
CT The best to examine renal parenchyma
Expensive
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Persistent microscopic Hematuria
Evidence of glomerular disease
Renal parenchymal disease evaluation Urologic evaluation
Renal Biopsy Risk of urologic malignancy- Age > 40 years- Heavy smoking- Pelvic radiation- Exposure: dyes benzene- Chronic urological tract
infection
Yes
Yes
No
No
- Urine 24-hr, calcium- Imaging- Cystoscopy + Cytology
- Imaging- Cystoscopy + Cytology
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Obstructive Uropathy
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Definition
• Functional or anatomic obstruction ofurinary flow at any level of the urinarytract
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Classification
Obstructive uropathy may be classified in to- congenital/acquired- Benign/malignant- Partial/complete- Unilateral/bilateral- Acute/Chronic
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Etiology
Congenital• meatal stenosis• ureteral strictures• posterior urethral strictures• ureterovesical junction
obstruction ureteropelvic junction
obstruction (various causes)• neurologic deficites
Acquired• urethral strictures
inflammatory or traumatic• bladder outlet obstruction• vesical tumor• neurogenic bladder• extrinsic ureteral
compression• ureteral or pelvic stones,
strictures and tumor
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History taking: Present Illness
A. Symptoms
1. Lower urinary tract (urethra and bladder)-hesitancy-lessened force and size of the stream-terminal dribbling
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History taking: Present Illness
2.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
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Physical Exam: Present Illness
B. Signs1. Lower urinary tract
-Palpation of urethra-Vesical distention
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Physical Exam: Present Illness
2. Upper urinary tract-Palpation of kidney
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Pathogenesis (pathophysiology)
The changes in the various segments in the urinary tract, depending on the obstructive severity and duration
1. Urethral changes: dilatation, diverticulum
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2. Bladder changes: trabeculation , trigone hypertrophy , diverticulum
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• 3. Ureteral changes: distention, dilatation and hydroureter
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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.
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Clinical findings
1.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
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Clinical findings
2.Laboratory findings•Urinalysis•BUN •Creatinine•Impaired kidney function elevated blood urea nitrogen and serum creatinine
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Clinical findings3.X-Ray findings , IVP, Cystoscopy , Retrograde
pyelography• localizing the site of obstruction• demonstrate the extent of the obstructed
segment• anatomic changes • functional changes
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Clinical findings
4.Special Examination Instrumental calibration of sites of obstruction
is also valuable• radioisotope renography• ultrasonic examination shows hydronephrosis
and residual urine • Urine flow rate• CT
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Treatment
• 1. Relief of obstruction-BPH or obstructing bladder tumors require surgical removal -impacted stones must be removed
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Treatment
2.urethral stricture can be dilatated or urethrotomy or urethroplasty
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Treatment
3.Percutaneous nephrostomy or double –J stent4.GFR< 10% : nephrectomy
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Thank You