24 Non-Glomerular Hematuria Flashcards
1
Q
Non-Glomerular Causes of Hematuria:
DDx & Work-up
A
- 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
- Urinalysis
2
Q
Hematuria of Cancer
A
- 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
3
Q
Hematuria from Trauma
A
- 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
4
Q
Blunt Renal Trauma
- Etiology
- Grade
- W/ microscopic hematuria
- CT
- Treatment
A
- 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
- Observation
5
Q
Penetrating Renal & Bladder Trauma
A
- 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
6
Q
Ureteral Trauma
A
- Rare
- Deceleration injury or penetrating trauma
- Iatrogenic causes
- Incidental congenital anomalies
- Uretero-pelvic junction obstruction
- Surgical repair
7
Q
Blunt Bladder Trauma
A
- 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
8
Q
Rupture of the Membranous Urethra
A
- 10% pelvic fractures in males
- GROSS BLOOD AT MEATUS
- Retrograde urethrogram
- Operative realignment
- Open or endoscopic
9
Q
Straddle Trauma to the Bulbar Urethra
A
- Butterfly hematoma
- Treatment: extended drainage
- Long term: stricture disease
10
Q
Injury to the Penile Urethra
A
- Penetrating trauma or sexual activity
- Fractured penis
- Gross blood
- Retrograde urethrogram
- Open surgical repair
11
Q
Kidney Stones:
Calculus Disease
A
- 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
12
Q
Kidney Stones:
3 Theories of Stone Formation
A
- 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
13
Q
Kidney Stones:
Calcium Oxalate Monohydrate or Dihydrate:
Pathogenesis / Risk Factors
A
- Idiopathic
- Metabolic defects
- Alkaline urine pH
- Hypercalciuria
- Hyperoxaluria
- Hyperuricosuria
- Family history
- Dehydration
- Diet or medications
- Vitamins A, D, C
- Acetazolamide
- Antacid abuse
14
Q
Kidney Stones:
CaOx Features
A
- 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
15
Q
Kidney Stones:
Hypercalciuria
A
- 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
16
Q
Kidney Stones:
Other Hypers
- Hyperuricosuria
- Hyperoxaluria
A
- 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
- Increased production
17
Q
Kidney Stones:
Enteric Hyperoxaluria
A
- 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
18
Q
Kidney Stones:
Calcium Oxalate Diagnosis & Treatment
A
- 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
19
Q
Kidney Stones:
Calcium Phosphate
- Pathogenesis/risk factors
- Clinical features
- Diagnosis
- Treatment
A
- 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
- Urinary acidification defect
- Hypercalciuria
- 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
20
Q
Kidney Stones:
Urate Nephropathy
A
- 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
21
Q
Kidney Stones:
Uric Acid Calculi
- Pathogenesis
- Clinical features
- Diagnosis
- Treatment
A
- 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
- Hyperuricosuria
- 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
22
Q
Kidney Stones:
Struvite Stones
- Pathogenesis / risk factors
- Clinical features
- Diagnosis
- Treatment
A
- 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
- Urinary tract infection with urea-splitting organism
- 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
23
Q
Kidney Stones:
Cystine Calculi
- Pathogenesis / risk factors
- Clinical features
- Diagnosis
- Treatment
- Drugs
A
- 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
- Autosomal recessive genetic defect in dibasic amino acid transport in renal tubule and gastric mucosa
- 1% of all stones
- Cystinuria
- 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
- Alkali therapy – Potassium Citrate
24
Q
Kidney Stones:
Inhibitors
A
- 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
25
Q
Kidney Stones:
Clinical Features & Treatment Options
A
- 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
26
Q
Kidney Stones:
Acute Management
- Diagnostic Procedures
- Treatment
- Surgery
A
- 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
- History and physical examination
- 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
- If small calculus in the lower or middle third of the ureter
27
Q
Kidney Stones:
Diagnostic Procedures
- CT Scan without contrast
- More Diagnostic Procedures
A
- 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
- IVP = intravenous pyelogram
28
Q
Bladder Stone Surgery
- Extracorporeal Shock Wave Lithotripsy - ESWL
- Staghorn Calculi
A
- 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%
29
Q
Percutaneous Nephrolithotomy:
Chronic Management
- Metabolic Work Up
- Treatment
A
- 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
30
Q
Percutaneous Nephrolithotomy:
Drug Therapy
A
- 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
31
Q
Percutaneous Nephrolithotomy:
Prostate
- Benign Prostatic Hyperplasia
- Photovaporization of the Prostate
A
- 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
- Minimally invasive
- Photovaporization of the Prostate
- Equivalent results to TURP
- Less side effects
32
Q
Renal Cystic Disease
- Simple Renal Cysts
- Adult Polycystic Renal Disease
A
- 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
33
Q
Renal Cystic Disease
- Infectious Causes
- Miscellaneous Rare Causes
A
- 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
