HaematuriaDefinition

passage of red blood cell in the urine. can be detected by dipstick/frank blood. Frank haematuria (35% has urological malignancy).Therefore, frank haematuria, think

renal/bladder Ca.CausesOrgan DDx HxRenal Glomerular disease

Polycystic kidneyCarcinomaStoneTrauma(inc.Bx)TBEmbolismRenal vein thrombosisVascular malformationUTI

Family HxFamily HxPainful haematuria?loin pain?anorexia?weight loss?PUOPainful haematuriaHx of trauma?Scan?Hx or travel

Fever,vomiting,loin painUreter Stone

NeoplasmLoin pain (stone)-colicky pain if obstructed, clot colic (neoplasm),

Bladder CarcinomaStoneTraumaInflammatory eg. Cystitis, TB, schistosoma

Painless haematuria,pelvic pain, recurrent UTI, dysuria- (neoplasm), suprapubic discomfort (bladder stone), terminal bleeding with pain (bladder stone)Total haematuria thru the stream-bleeding from bladderTerminal haematuria at the end of stream-rare but classical presentation of schistosomiosis.Frequency, dysuria,urgency

Prostate BPHCarcinoma

Terminal haematuria at the end of streamCheck for symptoms of prostatism-difficulty starting, poor stream, nocturia

Urethra TraumaStoneUretritisNeoplasm

Urethral injury- pelvic # or falling astride or recent intercourseUrethral bleeding independent of micturation (urethral lesion)Initial haematuria at the start of stream-urethra

Gen Anticoagulant TherapyThrombocytopeniaHaemophiliaSickle cell diseaseMalariaStrenuous exercise

Spontaneous bruising?Exposure to malaria?Family hxIf young and fit-exercise?

Red urine HaemoglobinuriaMyoglobinuriaAcute intermittent porphyriaBeetrootSenna

Crush injuries or ischemia of muscle

Take drug Hx, hx of malaria, TB

Ingestion?

PhenolphthaleinRifampicin

Examination

General weight loss,muscle wasting, cachexia,skin bruising/bleeding siteChest coarse crackle, reduce air entry-TB, secondary deposits from carcinoma of

kidney

Abdominal mass palpable mass eg. Hypernephroma, distended bladderRectal examination smooth enlargement of prostate (BPH), hard craggy prostate (carcinoma)

Urethral examination Feel for stone, neoplasmMuskuloskeletal bone tenderness-secondary deposit from carcinoma of prostate,

hypernephroma, bladder

Investigation

a)General IxIx What we rule in/out?FBC,ESR ↓Hb-gross haematuria,malignancy

↑Hb-polycytemia ass. with hypernephroma↑WCC-infections↓Platelets-blood dyscrasia↑ESR-malignancy,TB

Urine Microscopy Red Cells-excludes haemoglobinuria and ingestions of substances that cause discolouration of urineWhite cells-infectionOrganism-infectioncytology

MSU Culture and sensitivity -infectionU&E Renal failureClotting Screen Anticoagulant therapy, blood dyscrasiaCXR Metastases (cannonball metastases with hypernephroma),TBKUB Renal calculus-80% of stone visible on Xray

Specific Investigation

Test Disesase for confirmationPSA Prostatic carcinomaSickling test SCDIVU Stone, tumour,TB,traumaUSS Cystic vs solid, stone, urinary tract obstruction/abnormalitiesCT/MRI Tumour(conformation and degree of invasion),cyst,obstructive

uropathy,stone (99% visible and better than IVU to detect stone;Good TRO AAA if presentation is abdominal pain)

Cystoscopy Infection,tumour,stoneUteroscopy Tumour,obstructionSelective renal angiography Vascular malformation,tumourRenal bx Glomerular disease,tumourProstatic bx Carcinoma of the prostate

Treatment: Depends on the causes

Disease Initial ManagementRenal Stone Immediate analgesia eg. Diclofenac (IM/suppository) or pethidine IM with

metoclopramide IM +antibiotics.Emergency Sx if renal obstruction shows by imaging

Renal tumour Radical nephrectomy for local diseas and immunotherapy Ureteric tumour Referral for stenting to relieve obstruction ± resection of tumour

with/without nephrectomy/cystectomy depending on site.Bladder tumour Depends on staging

T1-local excision by transurethral cystoscopy and diathermy followed by intervesicular chemotherapeutic agents eg.mitomycinT2-T3-radical cystectomy with post op chemoT4-palliative chemo/radiotherapy

Bleeding diathesis If on warfarin and INr> 3.5, stop or adjust dose;if INR >> 3.5, vit K therapy. Otherwise, detailed assessments of clotting /platelets abnormalities and appropriate therapy.

Renal stones Due to crystal aggregates. Form in collecting duct. May 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 75% Magnesium aluminium phosphate. 10 – 20%

Struvite Triple phosphate.

Others. Urate 5% Hydroxyapatite 5% Cysteine 1% Brushite Mixed

Type Causative factors Appearance on X – rayCalcium oxalate Metabolic

IdiopathicSpikeyRadiopaque

Calcium phosphate MetabolicIdiopathic

SmoothMay be largeRadiopaque

Magnesium aluminium phosphate

UTI-recurrent Large horny (‘Staghorn’)Radiopaque

Urate Hyperuricaemia SmoothBrownRadiolucent

Cystine Renal tubular defect, YellowCrystallineSemi – opaque

Clinical pictureso May be asymptomatic.o Pain.

Kidney Ureter Bladder/Urethral

loin pain renal colicRadiates from loin to groinNauseaVomitingPatient unable to lie still-in peritonitis, pts lie still.

pain on passing urine.Poor urine flow.Intermittent urine flow

o Infection. Can co – exist with stones. Presents with.

Cystitis Pyelonephritis Pyonephrosis-pus collect in renal pelvis

Others

FrequencyDysuria

FeverRigorsLoin painNauseaVomiting.

Infected hydronephritis. HaematuriaProtenuriaSterile PyuriaAnuria

In HxDiet Oxalate levels ↑-Chocolate,Tea,Rhubarb,SpinachTime of the year Increased sunlight in summer increases Vitamin D synthesis, and so calcium and

oxalate levelsOccupation Can they drink freely?Is there risk of dehydration?Drugs Loop diuretics, Antacids, Acetazolamide, Corticosteroids, Theophylline,Aspirin

Thiazide diuretics, Allopurinol, Vitamin C & D, Indinavir (HAART)Risk factor Recurrent UTI- Magnesium aluminium phosphate stones.Metabolic Abnormalities

Hypercalciuria/Hypercalcaemia;HyperparathyroidismNeoplasia; Sarcoidosis;HyperthyroidismAddison’s syndrome,Cushing’s syndromeLithium, Vitamin D excessHyperuricosuria; Uraemia(alone /with gout)Hyperoxaluria, Cystinuria,Renal tubular acidosis

Renal tract abnormalities

Horse shoe kidney, hydronephrosis, ureteral stricture, etc

Family history. Increases risk of stones 3X.Specifically-askX – linked nephrolithiasisDent’s disease

Proteinuria Hypercalciuria Nephrocalcinosis

Infection above the stone-urgent intervention

Fever, loin tenderness, pyuria

Treatment1. Analgesics ie. NSAIDS diclofenac 75mg IV/IM/suppository (100mg) or Morphine 5-10mg with

10mg metaclopromide.2. Give fluids (if unable to tolerate orally) +antibiotics eg cefuroxime 1.5g/8H3. If obstruction-----refer urologist for further management

Optionsa) Extracorporeal Shockwave Lithotripsy (ESWL)b) Percutaneous Nephrostomy to relieve obstructionsc) Uteroscopy±laserd) Percutaneous nephrolithotomye) Open sx-rare

Renal Cell Carcinoma/Hypernephroma

Origin- Proximal convoluted tubule epithelium.Epidemiology-most common renal tumors in adult (90% of renal Ca)- present mostly on 5th decade (mean age 55)-M:F=2:1-15% pts on haemodialysis dev RCC

Clinical FeaturesMost common Haematuria, loin pain, mass in flankOthers Malaise, weight loss, aneroxia,fever,

Occasionally polycytemia, Varicocele (2%)- the enlargement of one testicle 25% have metastases at presentation to bone,liver,lung (Xray-cannonball metastases)

Spread-direct(renal vein), lymph nodes and haematogenous.

InvestigationsBlood FBC(polycytemia), ESR, U&E, alk phosUrine RBCs,CytologyImaging USS, CT/MRI, IVU, renal Angiography, CXR,Bx for cell type

TreatmentSx-radical nephrectomy gold standard -Unless bilateral involvement/contralateral kidney fx poorlyMetastatic disease medroxyprogesterone may control metastasis

Consider Immunotherapy with interferon α or interleukin 2

Prognosis=45% 5 year survival.

Bladder Tumour Commonest form of urological ca majority of Transitional Cell (urothelial)type other type includes adenocarcinoma and squamous cell carcinoma(may follow schistosomiasis) Common after age 40;M:F =4:1 Spread-direct invasion to adjacent structure,lymphatic spread and haematogenous spread late.

Risk Factors1. Smoking2. Industrial chemical eg. Aromatic amines (rubber/dye industries)3. Drugs eg. Phenacetin,cyclophosphomide4. Chronic inflammation eg. Stone,Schistosomiosis-scc, chronic cystitis5. Pelvic Irradiation6. Bladder diverticulae7. Persistent urchal remnant-adenocacinoma

Presentation-painless haematuria, painful if clot retention,recurrents UTI and voiding irritability-also dysuria,frequency,urgency

Examination usually –Ve in early stage. Tumour may be palpable on EUA

Investigation

Blood FBC-Hb↓,ESR↑,U&Eurine Creatinine, MSU & CS, urine microscopy&cytology (ca may cause sterile pyuria) ie WCC ↑, but

sterile culture.Others Cystoscopy with Bx-diagnostic

IVU-filling defect, bimanual EUA-may help in staging,CT/MRI-lymph/pelvic nodes involvement

Histology important for prognosisGrade 1-well differentiated Grade2 –intermediate Grade 3-poorly differentiated

Stage Tumour location Ex under Anas Tx Tis Ca in situ

impalpable

1. Diathermy/endoscopic resection ± intravesical Chemo (mitomycin) if high grade 3/multiple tumour evidenced to ↓recurrence

2. High grade/ca in situ-immunotheraphy

Ta Tumour confined to epithelium

T1 Tumour in lamina propria

with intravesical BCG may prevent progression

NB: T1 has 70% chance of recurrence in 5 years and 10% of dev. Invasive disease.Hence do cystoscopy at 6M/1Y interval for life!

T2 Superficial muscle involve Localize rubbery thickening

1. Radical cystectomy-gold standard2. Post-op chemo eg

cisplatin/methotraxate is toxic but effective

3. Radiotherapy has worse 5 years survival than sx but bladder preserve

4. Formation of neobladder-young, well motivated and high chance for cure from cystectomy.

T3 Deep muscle involved Mobile mass

T4 Invasion beyond bladder;in pelvic

Fixed mass 1. Palliative chemo(eg cisplatin)/radiotherapy

2. Cystectomy for intractable bladder symptoms

3. Chronic catherization/urinary diversion

Urinary Tract Infection (UTI)

Definition: Presence of pure growth of 10 5 of organism per ml of fresh MSU.Sites: Urethra(uretharitis), bladder(cystitis),prostate(prostatitis),renal pelvis (pyelonephritis).Recurrent-further infection with new organismRelapse-further infection with the same organism.

1/3 of women with symptoms has bacteriuria (abacterial cystitis/urethral syndrome)Classification

Uncomplicated Normal renal tract and F(x)Complicated Abnormal renal/GU tract,↓RFT,impaired host defences,virulent organism (stap.aureus),

men-until proven otherwise

PathogenesisInfection of UT usually via ascending transurethral route-facilitated by intercourse n catherization.Women-more susceptible ?1.short urethra2.proximity to anus facilitates transfer of bowel organism to bladder.

Risk factorsFemale, sexual intercourse,exposure to spermacide in female thru condom/ diaphragm, pregnancy,menopause,↓ host defence, immunosuppression, DM, Urinary tract obstruction, stones, cathether, UT malformations

Organism

Common E. coli (>70% in community, ≤41% in hospital),staph saprophyticus (10%),proteus mirabilis (12%)

Rare Enterococcus faecalis, klebsiella,enterobacter,acinetobacter species,pseudomonas aeruginosa,candida albicans, staph aureus

Symptoms

Cystitis Frequency, dysuria, urgency,strangury*,haematuria,suprapubic pain,* a slowand painful discharge of urine drop by drop produced by spasmodic muscular contraction of the urethra and bladder

Acute pyelonepritis

High fever, rigors, vomiting, loin pain & tenderness,oliguria (if ARF)

Prostatitis Flu like symptoms,low backache, few urinary symptoms, swollen/ tender prostate on PR exam

NB: In elderly, symptoms may be atypical with incontinence,nocturia/just vague change in well being.

SignsFever, abdominal/loin tenderness,foul smelling urine (esp lower UT), may also present with distended bladder,enlarged prostate.NB :vaginal discharge esp. offensive one → check for foreign body ie.tampon! or STI (candida,TV,BV,gonorrhea)

TestUrine Dipstick Nirates and leucocytes +ve- treat empirically

MSU (C&S) Confirm infections and antibiotics sensitivityMandatory- male,child, pregnant,immunosuppressed/ill,symptoms do not resolve with one course of empirical antibiotics

Blood haematology FBC,WCC,ESRbiochemistry U&E,CRPMicrobiology Culture & sensitivity

Imaging USS/IVU/cystoscopy To look for physiological and anatomical abnormalitiesKUB Xray

Indications for imaging1. After a single UTI in children or men2. Failure to respond to tx3. Recurrent UTI ≥ 2 years4. Pyelonephritis5. Unusual organism6. Persistent Haematuria

Also women with relapse (within 7 days of completions of antibiotics) & women with recurrence infections (more than 2 in 6M) arising more than 2 weeks after tx.

Treatment

Conservative Drink plenty of H2O,urinate oftenSpecific Cystitis Trimetoprim 200 mg/12H PO (3D in F,7D In M) or

Cafalexin 1g/12H2nd line: Ciprofloxacin/co-amoxiclav PO (7D)

Acute Pyelonephritis

Cefuroxime 1.5g/8H IV then oral (7D)

Prostatitis Ciprofloxacin (500mg/12H PO),4 weeks

Prevention Prophalaxis antibiotics,continous /post coital

Drinking 200-750 ml cranberry/lingonberry juice /day@ take cranberry con concentrate juice -↓10-20% infection.

Complications-more likely with complicated infections 1. Renal papillary* necrosis2. Renal/perinephric** abscess with the risk of Gram –ve septicemia.

* renal papilla-location where Medullary pyramids empty urine into the renal pelvis

* cone-shaped retroperitoneal compartment containing the kidney, adrenal gland, perinephric fat, fibrous bridging septa, and a rich network of perirenal vessel and lymphatics