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Haematuria

Urinary Tract Infection :: Haematuria :: Erectile dysfunction :: Urinary Incontinence
Urinary stones :: Vescico ureteral reflux :: Benign Prostatic Hyperplasia :: Cancer

The Problem

Hematuria: from Hemat = blood and uria = of urine

Hematuria simply means blood in the urine. Microscopic hematuria means that the blood is only seen when the urine is examined under a microscope. Gross hematuria, on the other hand, means that there is enough blood in the urine so that the change can be appreciated with the naked eye. Obviously, gross hematuria has more blood in the urine than microscopic hematuria, but the types of diagnoses that can cause the problem are the same and the work-up or evaluation that is needed is often identical.

Anatomy

To understand the needed evaluation for haematuria, one must know the anatomy of the urinary tract in the male. The kidneys function to make urine by filtering the blood and discarding into the urine the waste products that are no longer needed. Water and salts accompany these waste products by necessity. The urine is then transported through two narrow tubes, called ureters, to the bladder, which is the reservoir for urine in between each void. The urine exits the bladder through a channel called the urethra that first passes through the prostate and then through the penis to the outside.

The blood in the urine must come from one of the above places: kidneys, ureters, bladder, prostate, or urethra. The evaluation requires that we look at the ENTIRE urinary tract in patients with haematuria.

Causes

The number of causes of haematuria is large -- perhaps 20 or 25 different groups of causes. The potential causes vary in incidence according to the age of the patient.

Some are much more serious than others and require diagnosis sooner than later. These groups include cancers or malignancies, stones, infections, and blockages or obstructions to flow.

In the case of cancers, one must be concerned with every organ in the urinary tract, thus the reason to look at the entire urinary tract. Of the other groups, many are less important and most require no treatment. These may include viral infections, non-specific inflammations of the kidney such as drug reactions (non-steroidal antiinflammatory drugs, such as ibuprofen can cause non-specific inflammation, usually without harm). Many medications can cause blood in the urine, particularly medications which thin the blood's clotting ability, like coumadin or aspirin. Reddish discolouration of the, simulating haematuria , can also occur due to unusual causes such as excessive ingestion of beetroot or vitamins.

Degree of Haematuria

Haematuria is usually characterised as being either macroscopic (visible to the naked eye) or microscopic (detected only by laboratory tests). The distinction is important as it determines the likelihood of disease in the urinary tract and determines the extent of how far we may proceed with investigations. Typically, microscopic haematuria is described as the presence of more than 10 red blood cells per microlitre of urine. A microlitre is one millionth part of a litre. At low levels of microscopic haematuria, the chance of sinister pathology in the urinary tract is low. At a level of 20 red blood cells the chance of finding pathology causing such is ~ 8%. At a level of 50 red blood cells the chance rises only to ~ 13%. At a level of 100 red cells the chance of finding pathology on investigation is the same as for visible or macroscopic haematuria. Even with visible bleeding in the urine the chance of finding pathology causing such is only 70%. This means that we cannot determine the cause in ~30% of people. In that 30% and in a large proportion of the 70%, the causes are totally benign.

Evaluation

The evaluation consists of taking a history and doing a physical exam of the individual and analysing the urine under a microscope. Many questions about one's urinary tract, including urination habits, stone disease, infections and injuries, will be asked. In addition, we will ask about recent illnesses, family history, drugs used in the recent past, prior operations, social habits such as drinking and smoking, and work related exposure to chemicals, especially organic solvents and pesticides. Regardless of the information generated, we will almost always continue with the diagnostic tests to look at the entire urinary tract. Even if something from the history is suspected, we must try to prove that nothing potentially harmful is also present.

It is most important in the case of microscopic haematuria to be certain about the degree of haematuria. To be certain of the level of red cell excretion we generally get 3 sequential urine tests with each test being obtained on the afternoon of a separate day. The shape of the red cells can sometimes tell us if the red cells have come from the kidney or not. In the case of low levels of microscopic haematuria more advanced tests should only be done after this.

There are usually two further diagnostic tests necessary to give us a look at the entire urinary tract. The intravenous pyelogram (IVP) and cystoscopy.

Intravenous Pyelogram (IVP)

The intravenous pyelogram or IVP (or IVU) is a special X-ray of the urinary tract. A series of X-rays are taken before and after a special colourless dye is injected into the veins. The dye, which contains iodine, fills the urinary system and multiple films are taken over a 30-minute period looking for abnormalities. A pressure belt may be placed on your stomach to help fill out the system better. At the end of the procedure the X-ray technician will ask you to empty your bladder in the bathroom and then one last X-ray film will be taken.

You will be given a prep sheet to describe the proper preparation for the IVP. Laxatives usually will be taken the night before the IVP and some fluid restrictions will occur the morning of the test.

Cystoscopy

Cystoscopy is a procedure that is used to visually inspect the bladder and the urethra (tube leading out of the bladder). This can be done in most instances without discomfort by the use of a local anaesthetic jelly (not a shot). The cystoscope or telescope, which is narrower than the urethra, is passed into the bladder and the inspection is carried out. In most instances the telescope used is a flexible fibre optic instrument that conforms to the shape of the urinary channel. The entire procedure takes less than 10 minutes. Afterwards you might expect a little discomfort with voiding and perhaps a spot of blood for a day or so. A warm bath helps to relieve this irritation and will wash off the soap we've used to prepare the area. You may receive antibiotics afterwards to prevent infection.

Other Tests

Other tests that might be needed depending on the findings of the IVP and cystoscopy are ultrasound or CT scan examinations of the urinary tract. These will be done if some question or abnormality is not answered or explained to the urologist's satisfaction. Other tests, such as special blood studies, are considered if some historical fact about you raises other possibilities.

In the end, we hope to find nothing seriously wrong with the urinary tract. In fact, the most common finding is that we cannot determine a cause of the bleeding. This is actually a good finding because it suggests that the cause is not something that will ever be harmful. Remember that the thrust of the work-up is to exclude harmful diagnoses such as cancers or stones. Many of the other diagnoses include inflammations of the kidneys (nephritis) and would require a kidney biopsy to make a diagnosis. If one's urinary function is normal and we do not find protein in the urine, then the nephritis is usually harmless. This makes the kidney biopsy more dangerous than the disease,so we elect not to go further in the workup. Simple benign enlargement of the prostate is a very common source of blood in the urine and requires no treatment if no significant blockage is present.

Follow-Up

If we find no cause for the haematuria, you will be referred back to your primary physician for follow-up. He or she will probably want to check your urine every year for a while to make certain that no changes are occuring. A blood test to check kidney function and a blood pressure check should be done as well, but then all of these tests are usually done regularly. Men over 50 should have a yearly PSA or Prostate Specific Antigen to screen for prostate cancer.

If the amount of haematuria continues without change and no other symptom arises, the workup need not be repeated.

No discussion of treatment has been offered here. There are too many diagnoses that can account for haematuria to cover them all. Once the workup is completed, we will be able to give you a better idea of the exact causes and treatments, if any, are needed.

If you have any questions about haematuria or any other related urinary problem, please don't hesitate to ask.

Some conditions associated with haematuria

Renal Tumours

The commonest primary renal tumour is renal cell carcinoma, an adenocarcinoma of collecting tubule origin. It commonly presents with haematuria although most are nowadays picked up incidentally by ultrasound scanning. Diagnosis is made by CT scanning and treatment is by surgical excision. Small tumours may now be treated by local excision with preservation of kidney function.

Transitional Cell carcinoma of the renal collecting system usually gives haematuria. Diagnosis may be difficult, requiring retrograde imaging and ureteroscopy. Treatment is by either local excision or, for high grade or larger lesions, nephro-ureterectomy. Immunotherapy is used for metastases with limited success; radiotherapy has little place except for palliation of bone metastases.

Benign renal tumours may cause both bleeding and diagnostic difficulty. They are, with the exception of the incidental and usually asymptomatic renal cyst, rare. Angiomyolipoma is a hamartomatous lesion, which may grow to great size and be associated with major haemorrhage; treatment is again surgical, conserving normal renal tissue where possible.

Renal Stones

Stone disease is very common, with concretions forming in the renal papillae, which then form a nidus for stone formation in the collecting system. While most stones may cause infection, one particular type (infection or matrix stone) is thought to be caused by bacteria that are able to split urea to form ammonium. Renal stones tend to be asymptomatic but may cause haematuria by either infection or direct irritation of the mucosa. They may also cause renal pain if large enough or obstructing. Diagnosis is by imaging, usually intravenous urography. Renal stones can usually be treated by extracorporeal shock wave lithotripsy on an outpatient basis, although large or complex stones may need percutaneous or open surgical removal.

Glomerulonephritis

Glomerulonephritis tends to present with microscopic haematuria. While pain may be associated, most cases will have either no symptoms or may show signs of renal failure. Investigation is as outlined above.

Pyelonephritis (ascending urinary tract infection)

Acute bacterial pyelonephritis results from bacteria ascending from the bladder either by direct spread (vesico-ureteric reflux) or possibly by periureteric lymphatic extension. Painless haematuria may occur but the symptom complex usually includes loin pain, fever and possibly septicaemia.

Papillary Necrosis

This condition occurs in diabetics and in patients with deficiencies of oxygenation, particularly sickle cell disease. It is characterised by a radiolucent filling defect on IVU and may usually be treated expectantly

Ureteric Stones

Stones may form in the kidney and drop into the tube to the bladder (the ureter ). They usually present with pain but may have haematuria as the only symptom. The presence or absence of obstruction and the size of the stone dictates management. Most ureteric stones will pass on their own but sometimes treatment by passing a telescope up to the stone to remove it is required.

Cystitis

Typically cystitis is painful and in men is commonly associated with bladder outflow obstruction. Schistosomiasis and drug related cystitis are rarer causes of bladder inflammation causing bleeding. Diagnosis is by urine microscopy and culture, assisted by cystoscopy and biopsy if necessary.

Bladder Tumours

Most of the interest in painless haematuria stems from the desire to diagnose bladder tumours at an early stage. Nearly all are transitional cell cancers, with smoking and aromatic hydrocarbon exposure being risk factors. Rarer bladder tumours include adenocarcinoma (usually arising from the urachus) and squamous cancer (associated with chronic inflammation and schistosomiasis).

Diagnosis is as outlined above with management depending on the stage and grade: 70% are superficial at presentation and are managed by transurethral surgery with or without the use of intravesical therapy. For invasive tumours the choice lies between radical cystectomy or radiotherapy. Metastatic disease may respond to platinum based chemotherapy.

Prostate Tumours

Benign prostatic hyperplasia is ubiquitous but rarely bleeds on its own: it may acute cystitis and in this case transurethral surgery is indicated. Diagnosis is by urinary flow assessment and bladder residual volume measurement. Prostate specific antigen levels should be checked to rule out prostate cancer, which while uncommon in the fifties does occur and may cause haematuria directly or by infection.

Diagnosis is by prostatic biopsy, usually with ultrasound control. Treatment depends on the stage and outlook, but local disease may be suitable for radical prostatectomy or radiotherapy while advanced disease responds to hormonal manipulation.

Rare Causes of Haematuria

Arteriovenous malformations, tuberculosis and arteritis may all cause haematuria. Patients on anticoagulants whose control is in the normal therapeutic range and who have haematuria must be fully investigated as above, since haematuria is not a normal consequence of anticoagulation

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