خون در ادرار - hematuria

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Hematuria 

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Pye blo) F + GROSS HEMATURIA: Visible blood in the urine ‏ا‎ Reel ese aod tae aA [cod blood loss, since as little as 1 mL of blood per liter of urine can induce a visible color change ‎MICROSCOPIC HEMATURIA:‏ كه ای ریت تفت ات یی ‎ee arse R ee teal Cure NM steed‏ ور ‎a positive dipstick test must alWays bevconnnned with microscopic examination of ‏حليلية حلينا‎ 

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CAUSES: Hematuria may be a symptom of an underlying disease, some of which are life threatening and some of which are treatable CAUSES. jpg age and duration.jpg 

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Investigations for assessment of urinary tract Useful screening test for diabetes, renal and hepatic disease May indicate infection or renal disease Diagnosis of UTI May detect anemia/polycythemia Raised in patients with renal failure Screening for metabolic disorders in renal calculi Tumor markers for prostatic ca and testicular ca pH, glucose, protein, blood, bilirubin, ketones, nitrates RBCs, WBCs, crystals, bacteria Number and type of bacteria Hb, platelets, WBCs Urea, creatinine, electrolytes Ca++, phosphates, uric acid, albumin PSA, AFP, HCG 1.Dipsticks 2.Microscopy and gram stain 3.Urine culture B. Blood analysis 

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Detect bony metastases, paget’s disease, soft tissue masses, abnormal calcification Delineates entire urinary tract Assessment of renal and scrotal masses and bladder emptying Useful in assessing prostatic disease Preoperative staging of renal carcinoma Assess function of each kidney independently Useful is assessing degree of ‘obstruction to micturition e.g.:BPH Differentiates between urge and stress incontinence Assessment of urinary tract for neoplastic or stone disease wu USG Transrectal USG ‏ىع‎ Radioisotope renography DTPA somnre-simercaptos DMsa. Urine flow rates Cystometry (static and ambulant) Cystoscopy Ureteroscopy Ureterorenoscopy 1. Structure 2. Function D. Urodynamics E. Endoscopy 

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:ای ۱۲۱۵۵ ۰ + All patients should have a urine culture to exclude infection prior to evaluation of hematuria. Patients who have a positive urine culture should be treated for infection with close follow-up. The urinalysis should be rechecked in six weeks to determine whether hematuria has resolved. * Urine cytology: + Voided urine cytology had been used historically to evaluate patients with gross and microscopic hematuria but is no longer recommended due to variable sensitivity and specificity. 

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Overall approach to the evaluation: positive dipstick for heme or with red or brown urine > microscopic analysis - iMD_Uptodate_Evaluation_of the adult.pdf 

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Key points: * woman during her ‏تيان‎ repeated later in the cycle once menstrual bleeding has ceased. * a patient shortly after vigorous exercise or acute trom inet} urinalysis should be repeated approximately four to six weeks later during a period of no exercise => + Patients who have findings suggestive of urinary tract infection urinalysis should be repeated approximately six weeks after completion of antibiotic therapy 

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In uninfected patients or those without findings suggestive of infection, the subsequent evaluation depends upon whether the hematuria is gross or microscopic: ‎CT and‏ ل ا ل ‎cM Me coca aula MVM ile) <M‏ 1ه ‎referred for urgent urology evaluation for cystoscopy and further evaluation.‏ ‎+ If there is gross hematuria without visible blood clot: ‎Y Patients with acute kidney injury or findings suggestive of glomerular bleeding should be referred to nephrology. ‎Nonpregnant patients without acute kidney injury or findings suggestive‏ لا ‎of glomerular ۱۵ CT and urology referral for cystoscopy.‏ ‎¥ Pregnant pri 2 should have renal and bladder ultrasound rather than CT, largely to rule out ureteral obstruction or urolithiasis; further evaluation should be avoided, if possible, until after delivery. 

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lf there is microscopic hematuria: ۰ ور ‎la eC‏ بر بر 0۵09 ‎a Une MCV ncur Un ctia ec coi Mitra av eae RNa Be‏ رو ‎Pessoa Mice Cla‏ ‎See Eee en ala ace euro eS MC eC ee aCe ag‏ ‎ENR eee a ‏ات‎ ‎aCe lg‏ ا ل ا ل ‎MarR NA Co eles [eae do not require imaging studies or‏ ور یر ‎ACC Naan ‏ا ا‎ cence ts ee Cen at cnn ec eae Rec ces 

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:جوا ۲۷50۳۵1 ¥ Concurrent pyuria and dysuria, which are usually indicative of a urinary tract infection but may also occur with bladder malignancy. ¥ A positive family history of renal disease, as in hereditary nephritis, polycystic kidney disease, or sickle cell disease. ¥ Unilateral flank pain, which may radiate to the groin, usually suggests ureteral obstruction due to a calculus or blood clot but can occasionally be seen with malignancy or IgA nephropathy. ¥ Recent vigorous exercise or trauma in the absence of another possible cause 

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Historical clues: ¥ Symptoms of prostatic obstruction in older men such as hesitancy and dribbling. The cellular proliferation in BPH is associated with increased vascularity, and the new vessels can be fragile. presence of BPH should not dissuade the clinician from pursuing further evaluation of hematuria, particularly since older men are more likely to have more serious disorders such as cancer of the prostate or bladder. Among those with gross hematuria in whom no other cause can be identified,finasteride usually suppresses the ‏يتلا‎ ¥ History of a bleeding disorder or bleeding from multiple sites due to excessive anticoagulant therapy. 

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Historical clues: ¥ Medications that might cause nephritis(Abx and analgesics) (usually with other findings, typically with renal insuficiency) ¥ Black patients should be screened for sickle cell trait or disease, which can lead to papillary necrosis and hematuria. See NI Mol an cele are ‏ل ا‎ olmre a icoolna Mitt lance) Ua Melg tuberculosis. ‎oS on‏ مر رت را ی و۱ ‎analgesic nephropathy, and other interstitial diseases.‏ 

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ات۱ ۷ ‏وطتال اصعصنعصم۳م عم عا 62۶ صعصصم۷ صا هتطحصهعط نرق‎ 20 ۱0۴۲ 6۲ menstruation, suggesting endometriosis of the urinary tract. Contamination with menstrual blood is always a possibility and should be ruled out by repeating the urinalysis when menstruation has ceased. ¥ Black patients should be screened for sickle cell trait or disease, which can lead to papillary necrosis and hematuria. یر ریت پر یت ریت و ‎AMC Nel Cel aCe‏ Y Sterile pyuria with hematuria, which may occur with renal tuberculosis, analgesic nephropathy, and other interstitial diseases. 

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The identfication of the glomeruli as the source of bleeding can optimize the subsequent evaluation. In particular, patients with clear evidence of glomerular hematuria may not need to be evaluated for potentially serious urologic disease unless there is some other reason to do so glomerular hematuria Color (if macroscopic) | Red or pink Red, smoky brown, or Clots: May be present | Absent Proteinuria 25 day | May be >500 mg/day RBC morphology ‘Normal Some RBCs are dysmorphic RBC casts Absent May be present 

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MULTI-SYSTEM: * SLE nephritis + HSP nephritis ۱ ‏تا وت‎ + Goodpasture syndrome + HUS زره ت۱9 Glomerular Hematuria: سرد درا + IgA nephropathy + Alport syndrome ٠ Thin glomerular BM disease تفت ی ۱ 

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LOWER URINARY TRACT: cystitis يك كيك يتنا coagulopathy heavy excersise UP] obstruction لح تك * extraGlomerular Hematuria: UPPER URINARY TRACT: ۱ ‏یل‎ ‎ATN رل را ‎Ce et‏ 0 ‎Tee)‏ یر ‎scD‏ 0لا PCKD 

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Transient or persistent hematuria = Asymptomatic ‏يتان‎ No obvious etiology can be identified in most patients with transient hematuria. Fever, infection, trauma, and exercise are potential causes of ‏ابیت یقرت ریت۱‎ Transient hematuria can also occur with urinary tract infection (cystitis or prostatitis). In this setting, hematuria is typically accompanied by pyuria and bacteriuria, and patients often complain of dysuria. A potential source of error is that dysuria (but not pyuria and bacteriuria) can also be seen with macroscopic hematuria from bladder cancer 

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RISK FACTORS FOR MALIGNANCY: | تا فطع طعتط ييا ما إممعغولط ومكامدم5ك Occupational exposure to chemicals or dyes History of gross hematuria History of chronic cystitis or irritative voiding symptoms History of pelvic irradiation History of exposure to cyclophosphamide History of a chronic indwelling foreign body History of analgesic abuse, which is also associated with an increased incidence of carcinoma of the kidney 

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REFRENCE: Uptodate (5 Dec 2017) www.medscape.com 

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THANKS FOR YOUR ATTENTION