Page 1323 - TNFlipTest

Toronto Notes 2019
Hematuria (Blood in the Urine)
Urology U5
Table 2. Etiology by Type
Pseudohematuria
Vaginal bleeding
Dyes (beets, rhodamine B in candy and juices)
Hemoglobin (hemolytic anemia) Myoglobin (rhabdomyolysis) Drugs (rifampin, phenazopyridine, phenytoin) Porphyria
Laxatives (phenolphthalein)
History
Infectious/ Inflammatory
Pyelonephritis Cystitis
Urethritis Glomerulonephritis Interstitial nephritis Tuberculosis
Malignancy
RCC (mainly adults) Transitional cell carcinoma Urothelial cancer Wilms’ tumour (mainly pediatric) Prostate cancer Leukemia
Benign
BPH Polyps Exercise- induced
Structural
Stones
Trauma
Foreign body Urethral stricture Polycystic kidneys Arteriovenous malformation Infarct Hydronephrosis Fistula
Hematologic
Anticoagulants Coagulation defects Sickle cell disease Thromboembolism
Common Urologic Causes of Hematuria can be Classified as:
TICS
Trauma/Tumour/Toxins Infection/Inflammatory
Calculi/Cysts
Surgery/Sickle cell and other hematological causes
Upper Tract Imaging Options
CT Urography (CTU): test of choice for renal parenchyma, calculi, and infections. Involves exposure to radiation and IV contrast (assess renal function and allergies)
U/S: Superior to IVP for evaluation of
renal parenchyma and renal cysts; limited sensitivity for UCC and small renal masses; U/S alone is insufficient for upper tract imaging
Intravenous Pyelogram (IVP): Traditional option but rarely used (replaced by CTU); reasonable sensitivity for UCC, but poor sensitivity for RCC
• timingofhematuriainurinarystream
■ initial: anterior urethra
■ terminal: bladder neck, prostatic urethra ■ total: bladder and above
• presence of blood clots
• LUTSandassociatedsymptoms
■ pyuria, dysuria: UTI
■ flank pain, radiation: ureteral obstruction
• lastmenstrualperiod,historyofkidneystones,UTI,orpreviousurologicsurgery
■ recent URTI, post-infectious glomerulonephritis, IgA nephropathy
• medications(bloodthinners,rifampin,phenazopyridine,phenytoin)
• riskfactorsformalignancy(smoking,chemicalexposures,hxofcyclophosphamidetherapy,pelvic
radiation)
Investigations
• U/A,urineC&S,urinecytology • imaging
■ lower tract: cystoscopy
■ upper tract: CT (gold standard), U/S
• CBC(ruleoutanemia,leukocytosis),electrolytes,Cr,BUN,INR,PTT,PSA
Acute Management of Severe Bladder Hemorrhage
• manualirrigationviacatheterwithnormalsalinetoremoveclots
• ContinuousBladderIrrigation(CBI)usinglarge(22-26Fr)3-wayFoleytohelppreventclotformation
■ should be done after manual irrigation of all clots • cystoscopy
■ identify resectable tumours
■ coagulate obvious sites of bleeding