Gross hematuria common Work-up as indicated and urine cytology Bladder cancer- Transitional cell –Urothelial cell Renal carcinoma Detected incidentally, not usually from hematuria Prostate cancer Dectected by PSA and rectal exam, not hematuria Urethral cancer Only GU cancer more common in females Urothelial cancer in proximal urethra Squamous cancer in distal

Blunt Renal Trauma Etiology Grade W/ microscopic hematuria CT Treatment

Etiology Motor vehicle accident’s Falls Contact sports Graded I - V W/ microscopic hematuria Work-up not necessary if hemodynamically stable Except children or clinical suspicion CT usually done for other injuries Treatment Observation Until urine clear Surgery Grade V Thrombosis of the main renal artery Multiple major lacerations Avulsion of the main renal artery and/or vein

Rare Deceleration injury or penetrating trauma Iatrogenic causes Incidental congenital anomalies Uretero-pelvic junction obstruction Surgical repair

Motor vehicle accident’s, deceleration injuries Gross hematuria typically present Types Contusion Extraperitoneal rupture 10% of pelvic fracture Treatment: bladder drainage Intraperitoneal rupture Surgical repair Retrograde urethrogram first

24 Non-Glomerular Hematuria Flashcards by Heather Acuff

Non-Glomerular Causes of Hematuria:
DDx & Work-up

DDx
- Cancer – until proven otherwise
- Trauma
- Stones
- Infection
- Iatrogenic
- Miscellaneous
Work-up
- Urinalysis
  - Upper vs. lower tract
- CT scan
  - (-) Contrast or (+/-) contrast
  - [Historical: Intravenous pyelogram (IVP)]
- Cystoscopy
- Retrograde urethrogram and cystogram
- 90% of work up will be negative

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Hematuria of Cancer

Gross hematuria common
Work-up as indicated and urine cytology
Bladder cancer- Transitional cell –Urothelial cell
Renal carcinoma
- Detected incidentally, not usually from hematuria
Prostate cancer
- Dectected by PSA and rectal exam, not hematuria
Urethral cancer
- Only GU cancer more common in females
- Urothelial cancer in proximal urethra
- Squamous cancer in distal

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Hematuria from Trauma

Blunt and penetrating renal trauma
Ureteral trauma
Blunt and penetrating bladder trauma
Rupture of the membranous urethra
Straddle trauma to the bulbar urethra
Injury to the penile urethra

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Blunt Renal Trauma

Etiology
Grade
W/ microscopic hematuria
CT
Treatment

Etiology
- Motor vehicle accident’s
- Falls
- Contact sports
Graded I - V
W/ microscopic hematuria
- Work-up not necessary if hemodynamically stable
- Except children or clinical suspicion
CT usually done for other injuries
Treatment
- Observation
  - Until urine clear
- Surgery
  - Grade V
  - Thrombosis of the main renal artery
  - Multiple major lacerations
  - Avulsion of the main renal artery and/or vein

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Penetrating Renal & Bladder Trauma

Both
- Stab or gun shot wound
Renal
- 88% associated with other organ injury
- After stabilization, surgical exploration
  - Rare to study
Bladder
- Diagnostic studies only if stable
- Surgical repair

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Ureteral Trauma

Rare
Deceleration injury or penetrating trauma
Iatrogenic causes
Incidental congenital anomalies
- Uretero-pelvic junction obstruction
Surgical repair

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Blunt Bladder Trauma

Motor vehicle accident’s, deceleration injuries
Gross hematuria typically present
Types
- Contusion
- Extraperitoneal rupture
  - 10% of pelvic fracture
  - Treatment: bladder drainage
- Intraperitoneal rupture
  - Surgical repair
Retrograde urethrogram first

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Rupture of the Membranous Urethra

10% pelvic fractures in males
GROSS BLOOD AT MEATUS
Retrograde urethrogram
Operative realignment
- Open or endoscopic

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Straddle Trauma to the Bulbar Urethra

Butterfly hematoma
Treatment: extended drainage
Long term: stricture disease

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Injury to the Penile Urethra

Penetrating trauma or sexual activity
- Fractured penis
Gross blood
Retrograde urethrogram
Open surgical repair

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Kidney Stones:
Calculus Disease

One of the most common renal diseases of the Western World
Present in Egyptian mummies dated to 4800 B.C.
2 to 4% of the American population are at risk of at least one stone episode
during his/her life time
50% of those will experience at least one further episode of stone formation over the ensuing 10 years
Stone disease accounts for 1 of every 1000 hospitalizations
- 200,000 hospitalizations per year
- Exceeding $400 million dollars annually

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Kidney Stones:
3 Theories of Stone Formation

Matrix Theory
- Organic matrix compounds present in all stones are causally related to stone formation
Inhibitor Theory
- Deficiency in the urine of substrates which normally inhibit crystallization and growth
Crystalloid or Precipitation-Crystallization Theory
- Supersaturation with respect to the stone-forming constituents
Reality: likely due to a combination of these theories

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Kidney Stones:
Calcium Oxalate Monohydrate or Dihydrate:
Pathogenesis / Risk Factors

Idiopathic
Metabolic defects
- Alkaline urine pH
- Hypercalciuria
- Hyperoxaluria
- Hyperuricosuria
Family history
Dehydration
Diet or medications
- Vitamins A, D, C
- Acetazolamide
- Antacid abuse

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Kidney Stones:
CaOx Features

Accounts for about 85% of all stones
Male to female ratio is 3-4:1
High incidence of stones in the South Eastern United States = Stone Belt [Texas to Virginia and south]
Hypercalciuria
- > 300 mg/24 hr in males
- > 250 mg/24 hr in females
Calcium homeostasis requires
- Hormones: 1,25 vitamin D, PTH
- Organs: bone, kidney, gut

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Kidney Stones:
Hypercalciuria

Increased gut absorption of calcium
- Increased 1,25 vit D (sarcoid, primary hyperparathyroidism)
- Dietary calcium excess
- Idiopathic
Increased bone reabsorption
- Primary hyperparathyroidism
- Distal RTA
- Idiopathic
Increased renal excretion
- Hypercalcemia of any cause
- Distal RTA
- Dietary sodium or protein excess
- Idiopathic hypercalciuria
- Renal leak

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Kidney Stones:
Other Hypers

Hyperuricosuria
Hyperoxaluria

Study These Flashcards

Hyperuricosuria
- Uric acid crystals may serve as a nucleus for calcium salt precipitation
Hyperoxaluria
- > 40 mg/24 hours
- End product of metabolism
- Forms an insoluble complex with calcium
- NOT pH dependent
- Causes:
  - Increased production
    - Congenital
    - Vitamic C (2 gm/day)
    - Ethylene glycol
  - Increased intestinal absorption
    - Dietary excess
    - Enteric hyperoxaluria
    - Dietary calcium restriction

Kidney Stones:
Enteric Hyperoxaluria

Study These Flashcards

Malabsorption syndromes
- Crohn’s disease
- Intestinal bypass
Pathophysiology
- Fatty acid soaps bind calcium in the gut
- Calcium prevented from complexing with oxalate
- Oxalate then “free” to be absorbed in large quantities
Paradoxical treatment
- Calcium or magnesium supplementation
- Treat the underlying condition

Kidney Stones:
Calcium Oxalate Diagnosis & Treatment

Study These Flashcards

Diagnosis
- Stone analysis
- Calcium oxalate crystals NOT diagnostic
- 24 hour urine studies
Treatment
- Decrease urinary calcium/sodium/oxalate/uric acid
- Inhibitors
- Fluids, treat underlying defect, education

Kidney Stones:
Calcium Phosphate

Pathogenesis/risk factors
Clinical features
Diagnosis
Treatment

Study These Flashcards

Pathogenesis/risk factors
- Hypercalciuria
  - Vitamin D intoxication
  - Hyperparathyroidism
  - Sarcoid
- Alkaline urine
  - Urinary acidification defect
    - Distal, Type I RTA
  - Acetazolamide
  - Milk-alkali syndrome
    - Excessive intake of milk/antacids to control dyspepsia: results in hypercalcemia
Clinical features
- Common minor constituent of garden variety calcium stones
- Pure calcium phosphate stones are rare
Diagnosis
- Stone analysis; crystals NOT diagnostic
- 24 hour urine studies: hypercalciuria
- Identify other causative risk factors
Treatment
- Decrease calcium excretion
- Fluids, Rx underlying defect, education

Kidney Stones:
Urate Nephropathy

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Uric acid stones
- Most common form of uric acid disposition in the urinary tract
Acute uric acid nephropathy
- Particularly malignant form of uric acid precipitation
- Chemotherapy for a lymphoma or leukemia
- May obstruct of the urinary tubules by sludging
- True crystals, or stones do not form
Chronic urate nephropathy
- Unrelated to stone disease
- Progressive disease occurring in a minority of gout patients
- Precipitates in the interstitium and pyramids
  - Interstitial nephritis

Kidney Stones:
Uric Acid Calculi

Pathogenesis
Clinical features
Diagnosis
Treatment

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Pathogenesis
- Hyperuricosuria
  - gout
  - psoriasis
  - Lesch Nyhan syndrome
    - Juvenile gout: x-linked recessive deficiency in enzyme hypoxanthine-guanine phosphoribosyltransferase (HGPRT): resulting in elevated uric acid
  - obesity
  - Status post chemotx
- Persistently acid, concentrated urine (pH < 5.5)
  - chronic diarrheal disease, esp. via ileostomy
- Uric acid solubility decreases 10-20x when urine pH falls 7 to 5
Clinical features
- 5-10% of all stones
- Only truly radiolucent stone
Diagnosis
- Stone analysis
- Uric acid crystals in the urine NOT diagnostic
- 24 hour urine studies: hyperuricosuria
Treatment
- Very susceptible to solubility conditions
- Alkalinization to reach urinary pH 6.5-7.0 (solubility product)
- Fluids, treat underlying condition, education

Kidney Stones:
Struvite Stones

Pathogenesis / risk factors
Clinical features
Diagnosis
Treatment

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Pathogenesis / risk factors
- Urinary tract infection with urea-splitting organism
  - Proteus - most common
  - Klebsiella
  - Serratia
  - Enterobacter
- Markedly alkaline urine (pH 7.5-8.0)
- Supersaturation with magnesium-ammonium phosphate
Clinical features
- Accounts for about 20% of stones
- Most common cause of staghorn calculi
- Most common stone in women and paraplegics
- Recurrent UTIs
  - Bacteria reside in stone (i.e. coral)
- 40% of struvite stones are mixed calculi
- Sequela
  - Progressive renal insufficiency
  - Urosepsis or perinephric abscesses
  - Obstruction
Diagnosis
- Stone analysis
- Struvite crystals diagnostic of UTI with urea splitting organism
  - NOT necessarily struvite stone
- Urinary pH 8 suspect struvite stones
Treatment
- Antibiotics
- Percutaneous surgery/lithotripsy
- Fluids, treat underlying disease, education

Kidney Stones:
Cystine Calculi

Pathogenesis / risk factors
Clinical features
Diagnosis
Treatment
Drugs

Study These Flashcards

Pathogenesis / risk factors
- Cystinuria
  - Autosomal recessive genetic defect in dibasic amino acid transport in renal tubule and gastric mucosa
    - COLA = cystine, ornithine, lysine, arginine
  - Only amino acid to cause clinical disease
- 1% of all stones
Clinical features
- Onset often in childhood or early adolescence
- Family history
- Staghorn calculi can form, mildly radio-opaque
- Progression to renal failure
  - Renal parenchymal damage
Diagnosis
- Stone analysis
- Cystine crystalluria
  - Hexagonal crystals
- Cyanide-nitroprusside test
  - Qualitative
- 24 hour urine studies
  - Quantitative
  - Homozygous vs. heterozygous
Treatment
- High fluid intake (4L/d)
- Patient education- compliance
- Resistant to ESWL
- Meds
Drugs
- Alkali therapy – Potassium Citrate
  - Increase in cystine solubility at urine pH > 7.5
- d-Penicillamine
  - Covalently bonds to cystine, making a soluble complex
  - Toxic – glomerulonephritis, Lupus syndrome, marrow depression
- Tiopronin (Thiola)—similar action to penicillamine but better tolerated

Kidney Stones:
Inhibitors

Study These Flashcards

Deficient in urine of stone-former
Citrate
- Forms a soluble Ca+2-citrate complex
- Increases urinary pH
- Hypocitraturia occurs in states of chronic metabolic acidosis (distal RTA, chronic real failure, acetazolamide therapy), K+ depletion and idiopathic cases
- Presumably raises the formation product of all types of calcium stones

Kidney Stones: Clinical Features & Treatment Options

* Dull ache in the loin from distention of the renal capsule * Renal "colic" from acute or transient obstruction * Lumbar area and radiates around and down into groin, testis, labia or thigh * Pain changes as calculus moves * Patient cannot get comfortable * Nausea, vomiting, abdominal distention * Hematuria - gross or microscopic—does not have to be present * Frequency and urgency * Fever/chills

Kidney Stones: Acute Management * Diagnostic Procedures * Treatment * Surgery

* Diagnostic Procedures * History and physical examination * Risk factors, associated medical conditions, medications * Urinalysis: pH, rbc, wbc, culture, crystals * Not all crystals are diagnostic of stone disease * Spiral CT without contrast * Current diagnostic test of choice * Patients unable to have contrast agents * Treatment * 90% of stones less than 5 mm in diameter will pass spontaneously * Increase fluid intake * Strain all urine to catch stone for analysis * Steroid, alpha-blocker, antibiotic * Indications for surgical intervention * Infected system * Obstruction persists \>4 weeks * Intractable pain or nausea * Stone unlikely to pass due to size * Surgery * If small calculus in the lower or middle third of the ureter * Ureteroscopy with basket or ESWL * May need to be fragmented to remove * Laser, pneumatic, or electrohydraulic * If large calculus and/or in the pelvis of the kidney, or upper third of the ureter * Ureteroscopy, percutaneous removal or ESWL

Kidney Stones: Diagnostic Procedures * CT Scan without contrast * More Diagnostic Procedures

* CT Scan without contrast * “Renal colic CT” * “Kidney stone protocol CT” * CT abd/pelvis without contrast, low dose protocol * Rapid and specific * More Diagnostic Procedures * IVP = intravenous pyelogram * Previously best first test * Evaluation for obstruction and location * Ultrasound * May diagnose obstruction * Locate radio-opaque calculi * Limited in ureteral calculi * KUB = x-ray of the abdomen with pelvis * Kidney, Ureter, Bladder

Bladder Stone Surgery * Extracorporeal Shock Wave Lithotripsy - ESWL * Staghorn Calculi

* Extracorporeal Shock Wave Lithotripsy - ESWL * Effective and safe procedure * Revolutionized the treatment of all types of stone disease * Typically first line therapy * Minimal anesthesia * Outpatient * Staghorn Calculi * Percutaneous surgery alone or with ESWL * Recurrence reported at 10-40%

Percutaneous Nephrolithotomy: Chronic Management * Metabolic Work Up * Treatment

* Metabolic Work Up * Blood chemistry: calcium, phosphate, bicarbonate, uric acid, BUN, creatinine * 24 hour urine collections on "normal" diet * calcium nl to 300 mg in M, 250 mg in F * uric acid nl to 800 mg in M, 750 mg in F * sodium desired 100-125 mEq * volume desired \>2000 ml * citrate nl 300-900 mg * oxalate nl \< 40 mg * cystine nl \< 100 mg * Stone analysis * Treatment * Fluid intake 24 hours/day \> 2-3 L/day * Dietary modification * Regulate urinary pH * Alkalinization: uric acid and cystine stones * Acidification almost never indicated * Cranberry juice NOT indicated

Percutaneous Nephrolithotomy: Drug Therapy

* Citrate * Alkalinization also for calcium phosphate stones * Thiazide diuretic * Decreases urinary calcium for calcium stones * Sodium cellulose phosphate * Binds calcium in the gut for absorptive hypercalciuria * Allopurinol * Decreases urinary uric acid for uric acid and calcium stones * Antibiotics * D-penicillamine * Thiola

Percutaneous Nephrolithotomy: Prostate * Benign Prostatic Hyperplasia * Photovaporization of the Prostate

* Benign Prostatic Hyperplasia * Common cause hematuria: turbulent flow * Symptoms determine therapy, not size! * Meds: alpha blockers, 5-alpha reductase inhibitors * Surgery * Minimally invasive * Microwave, laser, radiofrequency * Endoscopic Resection – transurethral resection of prostate (TURP) * Open surgery * Photovaporization of the Prostate * Equivalent results to TURP * Less side effects

Renal Cystic Disease * Simple Renal Cysts * Adult Polycystic Renal Disease

* Simple Renal Cysts * Not cause of hematuria * Definition * Homogeneous throughout * Smooth walls * Posterior enhancement (Ultrasound) * Adult Polycystic Renal Disease * 1 in 500 * Cause end-stage renal disease * Autosomal dominant * Involves nephron * Other organs * Pancreas, spleen, lungs * Hypertension common * Flank pain * No treatment necessary to cure, treatment symptoms

Renal Cystic Disease * Infectious Causes * Miscellaneous Rare Causes

* Infectious Causes * Cystitis * Urethritis * Prostatitis * Pyelonephritis * Examine urinalysis & culture * White blood cell’s, nitrate positive, leukocyte esterase positive * Miscellaneous Rare Causes * Instrumentation * Foreign body * Anticoagulation * Remember: something is bleeding * Chemotherapy * Cyclophosphamide

24 Non-Glomerular Hematuria Flashcards

(33 cards)