Haematuria
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Introduction

Haematuria is the passing of blood in the urine

  • Frank Haematuriais the presence of blood on macroscopic investigation (i.e. looking at the blood)
  • Microscopic Haematuriais where you can only see RBC’s on microscopic investigation
  • Haemoglobinurea is the presence of free haemoglobin in the urine
Haematuria always requires further investigation.
  • Initial haematuria – this is presence of blood in the urine when you first start micturating – this implies urethral damage
  • Terminal haematuria – this is the presence of blood in the urine at the end of the stream, and this suggests a problem with the prostate or bladder base.
  • Ribbon clots suggest a ureteric cause
  • Kidney bleeds can mimic renal colic as the clot passes down the ureter.

Causes

Kidney

  • Trauma – mild to moderate trauma often causes this, but severe trauma may not.
  • Tumours – can produce profuse or intermittent bleeding
  • Renal cell carcinoma there may be loin pain, colic caused by a clot, an associated mass, hypertension, hypercalcemia, erythrocytosis (aka polycythemia –increased number of RBCs)
  • Calculus – sever loin / groin pain, associated infection
  • Glomerulonephritis often associated systemic disease (e.g. SLE)
  • Pyelonephritis – (rare)
  • Renal TB (rare) – may be associated weight loss / anorexia, and sterile pyuria (urine that contains pus)
  • Polycystic disease – (rare)
  • Renal infarction – (rare)
  • TCC – painless, intermittent haematuria

Ureter

  • Calculus – sever loin / groin pain, associated infection

Bladder

  • Calculus – sudden cessation of micturition, pain in perineum and penis
  • TCC – painless, intermittent haematuria, history of work in the rubber / dye industries.
  • Acute cystits – frequency, dysuria (pain / difficulty micturating), bacteriuria
  • Interstitial cystits – a bladder condition of unknown origin, characterised by frequency, urgency and pain. It may be autoimmune, and sometimes caused b y radiation therapy.

Prostate

  • BPHpainless, haematuria, recurrent UTI, associated obstructive symptoms.
  • Carcinoma – rare cause of haematuria

Urethra

  • Trauma
  •  Calculus – rare
  • Urethritis – rare

Investigations

  • FBC – to test for infection, and chronic blood loss
  • Clotting to exclude an underlying bleeding cause
  • U+E – to asses renal function
  • MSU – to check for infection and parasites
  • Csytoscopy – if suspect a bladder cause
  • Autoimmune scan – if suspect glomerulonephritis
  • Intravenous Urography (IVU) / CT scan / ultrasound – if you suspect a renal cause

References

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Dr Tom Leach

Dr Tom Leach MBChB DCH EMCert(ACEM) currently works as a GP Registrar and an Emergency Department CMO in Australia. He is also a Clinical Associate Lecturer at the Australian National University. After graduating from his medical degree at the University of Manchester in 2011, Tom completed his Foundation Training at Bolton Royal Hospital, before moving to Australia in 2013. He started almostadoctor whilst a third year medical student in 2009. Read full bio

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