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57 Cards in this Set
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- Back
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Case: 40-year old male smoker is found incidentally to have RBCs in his urine sample on a urinalysis.
What is the current diagnosis? |
Asymptomatic microscopic hematuria |
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Case: 40-year old male smoker is found incidentally to have RBCs in his urine sample on a urinalysis.
How should this patient be approached initially? |
Repeat the U/A, assess for risk factors, image the upper and lower urinary tract |
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Case: 40-year old male smoker is found incidentally to have RBCs in his urine sample on a urinalysis.
How should this patient be worked up and treated? |
- Rule out infection by performing a urine culture - Evaluate for malignancy by imaging of the upper urinary tract, cystoscopy, and voided cytology |
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Case: 40-year old male smoker is found incidentally to have RBCs in his urine sample on a urinalysis.
What are your concerns? How should they be counseled? |
- Primary concern is to rule out malignancy including renal cell carcinoma and transitional cell carcinoma - Counsel the patient on the importance of an appropriate workup, but reassure the patient about the low prevalence of the condition |
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In a patient presenting with painless hematuria, what risk factors should you address to determine possible etiologies? |
- Risk for STDs - Occupational exposures to chemicals - Strenuous exercise - Drugs, meds, and herbal / nutritional supplements |
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A patient presents with painless hematuria, what should be done next? What results would prompt you to continue your workup? |
- Repeat urinalysis, also urine culture - If hematuria persists, get imaging studies of both upper and lower urinary tract
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How do you image the upper urinary tract? |
IV Pyelogram (IVP) or CT scan |
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How do you image the lower urinary tract? |
Cystoscopy (endoscopic procedure) |
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When should you refer a patient with hematuria to a urologist? |
If the workup reveals an abnormality that cannot be treated in a primary care office or if the condition persists |
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What is the likelihood that cancer will present as asymptomatic microscopic hematuria? |
Low (but worth ruling out) |
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What is "gross hematuria"? |
Presence of enough blood in a urine sample to be visible to the naked eye |
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What does the lower urinary tract consist of? |
- Urinary bladder - Urethra |
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What does the upper urinary tract consist of? |
- Kidneys - Ureter |
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What is "microscopic hematuria"? |
Presence of 3 or more RBCs per HPF on two or more properly collected urinalyses |
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What are the categories of etiologies that can cause hematuria? |
- Glomerular - Renal (non-glomerular) - URologic |
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What other findings is glomerular hematuria associated with? |
- Significant proteinuria - Erythrocyte casts - Dysmorphic RBCs |
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What other findings is renal / non-glomerular hematuria associated with? |
- Tubulointerstitial disorders - Renovascular disorders - Metabolic disorders
- May have significant proteinuria - No associated dysmorphic RBCs or erythrocyte casts |
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What other findings is urologic hematuria associated with? |
- Tumors - Calculi - Infections - Trauma - BPH
- NO proteinuria, dysmorphic RBCs, or erythrocyte casts |
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How do you define clinically significant hematuria? |
3 or more RBCs per HPF on microscopic evaluation of urinary sediment from two of three properly collected urinalysis specimens |
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What characteristics make an ideal urinalysis sample? |
- Freshly voided - Early morning - Clean-catch - Midstream - Urine must be refrigerated if it cannot be examined promptly, as delays of more than 2 hours between collection and examination often cause unreliable results |
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How can you measure hematuria quantitatively? |
- Determine the number of RBCs per mL of urine excreted (chamber count) - Direct exam of the centrifuged urinary sediment (sediment count) - Indirect exam of the urine by dipstick (simplest way to detect microscopic hematuria) |
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How useful is the dipstick method of urine examination for hematuria? |
- Limited specificity (65-99% for 2-5 RBCs per HPF) - unable to distinguish RBCs from myoglobin or hemoglobin - Needs to be confirmed by microscopic evaluation of urinary sediment |
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What are important risk factors for malignancy associated with hematuria? |
- Smoking - Occupational exposure to chemicals or dyes (benzenes or aromatic amines) - History of gross hematuria - Older than 40 years - History of urologic disease or disorder - History of irritative voiding symptoms - History of UTIs - Analgesic abuse - History of pelvic irradiation |
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What is the prevalence of asymptomatic hematuria in adults in the U.S.? |
0.20% |
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What should you do for a patient with asymptomatic hematuria who also has significant proteinuria, RBC casts, renal insufficiency, or a predominance of dysmorphic RBCs in the urine sample? |
Evaluate for renal parenchymal disease / refer to a nephrologist |
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How can you distinguish lower urinary tract bleeding from glomerular bleeding? |
- Lower urinary tract bleeding is associated with >80% normal RBCs - Glomerular bleeding is associated with >80% dysmorphic RBCs |
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What should you evaluate to diagnose a patient with renal parenchymal disease? |
Urinary sediment |
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What does looking at the urinary sediment help you determine? |
- Diagnose renal parenchymal disease - Differentiate between glomerular disease (RBC casts and dysmorphic RBCs) and interstitial nephritis (eosinophils in urine) |
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What should you consider if your patient has eosinophils in their urine sediment? |
Interstitial nephritis |
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What should you consider if your patient has RBC casts and dysmorphic RBCs in their urine sediment |
Renal glomerular disease |
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What should you do for a patient found to have hematuria who on repeat U/A does not? |
- If low risk, no further workup is needed - If high risk, continued workup is recommended |
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What can cause transient microscopic hematuria? |
- Sexual intercourse - Heavy exercise - Recent digital prostate exam - Contamination by menses |
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When should you do the repeat U/A in a patient with hematuria? |
Avoid any potential confounders such as menses, medications, exercise, drugs, and nutritional / herbal products (may need to consider a catheterized specimen with care not to induce trauma during the procedure) |
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How long does it take for exercise-induced hematuria to resolve? |
Spontaneously within 72 hours |
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What lab studies should be done first in evaluation of a patient with hematuria? |
- U/A with microscopy - Evaluation of centrifuged urinary sediment - Check for number of RBCs per HPF, dysmorphic RBCs, and presence of casts or eosinophils - Urinary culture (to rule out UTI) - Serum Creatinine |
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If a patient with hematuria has a UTI, how should workup proceed? |
Treat UTI, repeat U/A in 6 weeks; if it resolves with treatment than no further workup is needed |
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Why should you get a serum creatinine in a patient with hematuria? |
To check renal function, compare to old records if available |
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What should you focus your differential on if a patient with hematuria has an elevated creatinine? |
Renal parenchymal disease and possible etiologies such as HTN, diabetes, or auto-immune disease |
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How can you detect transitional cell carcinoma? |
Urine cytology - may not pick up low-grade but is fairly reliable for detecting high-grade lesions, especially if repeated |
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What is an IVP? |
X-ray imaging of the upper urinary tract after the administration of an IV contrast dye |
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What is the purpose of an IVP? Limitations? |
Widely available and relatively low cost; option for imaging the upper urinary tract
May miss small renal masses and may not distinguish solid from cystic lesions |
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Besides IVP, what are alternative imaging options for the upper urinary tract? |
- Ultrasound - CT scan |
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What are the benefits / limitations of ultrasound for assessing the upper urinary tract? |
- Widely available - Does not require use of IV dye - May miss small lesions |
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What are the benefits / limitations of CT for assessing the upper urinary tract? |
- High sensitivity and specificity for detecting masses, renal stones, renal or perirenal infections, and obstruction - Should be performed initially without contrast to detect calculi, and then with contrast |
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What study can combine the benefits of CT scanning and IVP? |
Multidetector CT urography - associated with high doses of radiation (not allowed in pregnant women) |
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Who is allowed to get a multi detector CT urography? |
- Non-pregnant patients - Some recommend only for patients >40 or patients <40 with known risk factors for genitourinary malignancies |
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What side effect can IVP and CT cause? |
Nephropathy due to IV contrast dye exposure |
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How can you limit nephropathy due to IV contrast dye exposure? |
Pre-medication with N-acetylcysteine or IV sodium bicarb |
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What imaging option should you consider for a patient with renal insufficiency or for someone at high risk for contrast nephropathy? Why is this less risky? |
Retrograde pyelography + renal U/S - In the retrograde pyelography a catheter is placed in the bladder and dye is injected up the ureters to the kidneys; little risk of contrast nephropathy because it is not being given IV |
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How can you evaluate the lower urinary tract for transitional cell carcinoma? |
Cystoscopy - by a urologist |
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When can you consider deferring a cystoscopy in the workup of hematuria? |
In a patient with no risk factors with a negative history, exam, lab workup, and upper tract imaging |
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What should you do for a patient with a thorough but negative workup for hematuria? |
Follow-up BP, U/A and voided urine cytologic studies at 6, 12, 24, and 36 months
If it remains negative at 36 months and the patient is still asymptomatic, no further follow-up is recommended |
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What should you do for a patient with a thorough but negative workup for hematuria who develops to have gross hematuria, voiding difficulties, pain, or any abnormal cytology? |
Immediate urologic reeevaluation and urologic consultation |
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What should you do for a patient with a thorough but negative workup for hematuria who develops HTN, proteinuria, glomerular casts, or abnormal renal function? |
Refer to a nephrologist for consultation |
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A 24 year old male bodybuilder with no significant PMH presents with gross hematuria. He was told my his trainer that exercise can induce hematuria and that this is nothing to worry about. He comes to you for a second opinion.
What is the most appropriate management at this time? |
U/A, urine culture, imaging of upper urinary tract by CT scan
- Gross hematuria always deserves a FULL workup. Although exercise-induced hematuria resolves in 72 hours, gross hematuria, especially in a person with risk factors must have a thorough evaluation |
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A 78- year old man with multiple medical problems with dysuria is found to have microscopic hematuria. His exam is only positive for a very tender and boggy prostate.
What is the next best step? |
Treat the prostatitis with 1 month of antibiotics and re-evaluate the patient with a follow-up U/A and culture post-treatment
- A tender/boggy prostate alludes to the diagnosis of prostatitis. Re-evaluation should be done after adequate treatment of the prostatitis. If the hematuria persists following treatment, further workup is necessary |
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A 45 year old woman with a history of cancer, currently receiving radiation therapy, presents as a new patient. On a routine U/A you discover 2 RBCs per HPF, 15-20 WBCs per HPF, nitrites, and leukocyte esterase.
What is the next best step?
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Repeat a clean-catch midstream specimen, send for culture, and treat the UTI. Repeat U/A after UTI treatment.
- True microscopic hematuria is the presence of ≥3 RBCs per HPF in a midstream clean-catch specimen after exclusion of UTI. If there is evidence of UTI it should be cultured, treated, and U/A repeated after treatment. |
