HEMATURIA

BY
GROUP A1
ARIF,RAHIMIE,SAFUAN,ALIA,SOFWATUL,AINUL,AMIRAH
 Definition??
• Hematuria is the presence of blood,
specifically red blood cells, in the urine. 
• It can be characterized as either
– “gross” (visible to the naked eye) or
– “microscopic” (visible only under a microscope)
 From the history…
• Blood during or after micturition?
• No visible changes in urine colour or little
darker than usual? suggest modest
bleeding.
• Resemble pure blood? heavy bleeding.
• Only at start of micturition and then clear?
frm urethra.
 From the history…
• Only at the end of micturition? frm bladder
neck or lower part of urinary tract or prostate.
• Throughout urination? bladder or above.
• Blood with painstone, infection
• Blood but painlesssuggestive of
malignancies
• Fever, dysuria, frequency,drug history…
 Embryology of urogenital system
• Urinary system involved
– Urinary bladder
– Urethra
– Kidneys & ureter
 Development of urinary bladder
• develops from the ventral part of the coloaca (primitive uro genital
sinus)
→endodermal in origin.
• Two mesonephric ducts descend and open at the dorsal surface of
the urogenital sinus dividing it into upper vesico-urethral part and
lower definitive Urogenital sinus.

• The vesico-urethral part connected to the umbilicus by the

allantois.
– The vesico-urethral part expand to form the bladder(Endoderm) and
the stem of the two mesonephric ducts absorbed to form the trigone
at the base of the urinary bladder which is mesodermal in origin.
• The allantois at the second month start fibroses and degeneration
to form the urachus that becomes obliterated and remain as
median umbilical ligament extend from apex of the bladder to
umbilicus .

• SO: ALL THE BLADDER IS ENDODERM EXCEPT THE TRIGONE

MESODERM
 Development of urethra
• wholly endoderm except the terminal part at
the glans penis (ectoderm)
♂ a) Upper part of prostatic urethera from the
vesico urethral part of ventral coloaca.
b) Lower prostatic and membranous part from
pelvic part of definitive uro-genital sinus.
c) The penile urethera (phallic part) develops
from the lower phallic part of definitive
Urogenital sinus except the part at glans penis
which is ectodermal in origin.
♀ At female the whole urethera endoderm from
urogenital sinus
 Development of kidneys and
ureter
• The kidney mesodermal in origin and it develops
• From two sources:
1) Metanephric cap: that develops from the lower Part of the
intermediate cell mass (nephrogenic cord) as mass of
mesoderm over the Ureteric bud .
2) Ureteric bud: that arises from the dorsomedial surface of
the mesonephric duct.
– Elongated ureteric bud form ureter

• NB:
– the fetal kidney is lobulated in shape
– The kidney develops in the pelvis and migrated cranially to the
lumbar region
– Kidney starts to secrete urine at the 10th week.
ANATOMY OF GENITOURINARY
SYSTEM
anatomy of kidney
• Location: retroperitoneal, opposite last thoracic +
upper 3rd lumbar vertebrae
• Size: 10 to 13 cm (4 to 5 inches) long
5 to 7.5 cm (2 to 3 inches) wide
~3 cm thick
• Weigh: ~150g
• Rt is lower ½ inches than lt
• Hilum: VAU
• Blood supply : renal artery
Anatomy of ureter
 Ureteral narrowings
• Uretero-pelvic junction
• Pelvic brim
• Opposite ischial spine (crossing iliac artery)
• Transition of ureters into bladder
Anatomy of urinary bladder
• Empty : most ant compartment of lesser pelvis
• Distended : into abdomen, pushes parietal
peritoneum
• Size : ~220cc until 500cc
• Nerve supply : sympathetic; T11,T12,L1,L2
parasympathetic; pelvic
splanchnic nerve (S2,3,4)
Blood supply : superior and inferior vesical artery +
additional branches
 Urethra
Male:
• 20 cm in length
• S-shaped
• From neck of bladder, extend through the prostate,
the pelvic diaphragm, spinchter urethrae, and the
root and body of penis to tip of the glans.
• Divided into 3 parts:
-Prostatic urethra
-Membranous urethra
-Spongy urethra
Female:
•4 cm long
•Distendable
•Extend downward and
forward from neck of
bladder to the external
urethral orifice (situated
between labia minora)
Male genital
• Testes  epididymis  vas deferens 
seminal vesicles - - (+ urethra) prostate,
ejaculatory duct, bulbo urethral gland  penis
Female genital
 PHYSIOLOGY
OF THE
URINARY SYSTEM
 Roles of the kidneys are:
• Regulation of plasma ionic composition.
• Regulation of plasma osmolarity.
• Regulation of plasma volume.
• Regulation of plasma hydrogen ion
concentration (pH).
• Removal of metabolic waste products and
foreign substances from the plasma.
• Secretion of hormones
Bowman's capsule
 Ureters

• The ureters are two tubes that drain urine

from the kidneys to the bladder.
 Urinary Bladder

• The urinary bladder acts as a temporary

storage of urine and able to hold
approximately 500 to 530 ml of urine
 Urethra

• The urethra is a muscular tube that

connects the bladder with the outside of
the body. The function of the urethra is to
remove urine from the body.
 Formation of Urine

• Urine is formed in three steps:

1. Filtration
2. Reabsoprtion
3. Secretion
• Filtration
– Blood in the glomerulus has both filterable blood
components and non-filterable blood components
– Filterable blood components
( water, nitrogenous waste, nutrients and salt (ions))
– Non-filterable blood components
(blood cells, plasma proteins)
 How does hematuria occurs?

• Hematuria may result from one of two

mechanisms:

1. Rupture/perforation of vessels in the urinary tract or

renal system
2. Impaired glomerular filtration
HAEMATURIA

Glomerular hematuria

Isolated hematuria
 Glomerular hematuria
Blood originating from the nephron

Resulted from abnormalities in the structure and

integrity of the glomerular capillary wall

results in persistent microscopic hematuria, with or

without periods of gross hematuria

RBCs can be trapped in Tamm-Horsfall

mucoprotein and will be manifest in the urine by
RBC casts
 Isolated hematuria
• Extraglomerular bleeding
• Without proteinuria or casts
• Irritation, inflammation, or invasion
 renal stones, trauma, infection, and
medications
tumors of the kidney
renal cysts and infarction

Blood is equally dispersed throughout the urine

stream and does not clot
• Initial hematuria
urethra or prostate

• Total hematuria
bladder, ureter, or kidneys

• Terminal hematuria
bladder or prostate
Causes of hematuria and
Investigation
Kidney
Ureter
Bladder
Prostate
Urethra
 Causes of hematuria
1) Stone
2) Tumor
3) Inflammation
4) Polycystic
5) Rupture
6) BPH
7) Medication
 Stones
• Occur in kidney, ureter, bladder and urethra
• M>F
• most common in people younger than 40
years old
• Stones from kidney can move to ureter
causing renal colic, usually a/w dysuria
• Common in patient with gaot,
hypercalcaemia, hyperparathyroidism,
cystinuria
 Diagnosis
• Base line investigation:
1- Urine
-microscopic study(protein, RBC, bacteria,crystal)
-culture of urine sample(to exclude urine infection
@ 2ry due to infection)
2- Blood
-FBC for ↑WBC
-RF for hypercalcaemia
3- 24 hour urine collection
-to measure total daily urinary volume,
magnesium, sodium,uric acid, calcium
 Diagnostic investigation
1- X-Ray
-includes the kidneys, ureters and bladder—KUB
followed by an IVP (intravenous pyelogram)
2- CT Scan
- gold standard diagnostic test for the detection
of kidney stones.
3- Ultrasound
-used to detect stones during pregnancy when x-
rays or CT are discouraged
Bilateral kidney stones on abdominal X-ray.
 Tumor
o kidney(RCC)
o ureter
o bladder(ca)
o urethra
o prostate(ca)
 Kidney Tumor
• Renal cell carcinoma-most common ca in adult

• Usually asymptomatic until late stage

• Elicit by signs & symptoms, physical
examination
Investigation
1. Complete blood count (CBC)
2. Liver function tests
3. Serum calcium
4. Urine cytology
5. Urine test (urinalysis)
6. Abdominal CT scan
7. Intravenous pyelogram (IVP)
8. Ultrasound

Extra:
-CXR,bone scan
 Ureter Cancer
•  known as renal pelvic cancer
• Ureteral cancer can be transitional cell
carcinoma 
• Cancer in this location is rare

Dx:
CT urography, MRU, x-ray, or biopsy
 
 Bladder Cancer
• called transitional cell carcinoma

Dx:
Gold standard for diagnosing→ biopsy during
cystocopy.
 Prostate Cancer
• the gold standard for diagnosing bladder cancer
is biopsy obtained during cystoscopy.
Investigation:
1. PSA test
2. Digital Rectal Exam
3. MRI scan
4. Ultrasound
5. CT scan
6. Biopsy
 Inflammation
-kidney(pyleonephritis)
-ureter(ureteritis)
-bladder(cystitis)
-urethra(urethritis)
-prostate(prostatists)
 Inflammation
Inflamation Investigtion/diagnosis

Pyelonephritis 1) Urine dipstick test

2) Urine culture
3) Blood culture
4) KUB x-ray
5) ultrasound
Urethritis Cotton swab into urethra then examine
under microscope
Cystitis 1) urinalysis-reveals WBC&RBC
2) urine culture
Prostatitis, ureteritis 1) urinalysis-WBC&bacteria
 Polycystic kidney disease (PKD)
• Genetic disorder characterized by the growth
of numerous cysts in the kidneys
• When cysts form in the kidneys, they are filled
with fluid
• PKD cysts can profoundly enlarge the kidneys
while replacing much of the normal structure,
resulting in reduced kidney function and
leading to kidney failure
• Two major forms of PKD:
• Autosomal dominant PKD
• is the most common inherited form. Symptoms usually
develop between the ages of 30 and 40, but they can
begin earlier, even in childhood. About 90 percent of all
PKD cases are autosomal dominant PKD.
• Autosomal recessive PKD
• is a rare inherited form. Symptoms of autosomal
recessive PKD begin in the earliest months of life, even
in the womb.
 Autosomal dominant PKD

• Autosomal dominant PKD is usually diagnosed

by kidney imaging studies
1. Ultrasound
2. Computerized tomography (CT) scans
3. Magnetic resonance imaging (MRI)
• Diagnosis can also be made with a genetic test
that detects mutations in the autosomal
dominant PKD genes, called PKD1 and PKD2.
• Criteria for diagnose autosomal dominant PKD
• > 30 years old
• Ultrasonography is the most sensitive
• two or more cysts in one kidney
• four or more cysts in subjects older than 60 years
because of the increased frequency of benign simple
cysts
• a positive family history
• Imaging studies showing large kidneys with multiple
bilateral cysts and possibly liver cysts
• < 30 years old
1.CT scan or T2-weighted MRI is more sensitive
 Autosomal dominant PKD
• Multiple, variably sized cortical and medullary
based cysts
• Renomegaly
• Hemorrhagic cysts are often present
 Autosomal recessive PKD

• Corticomedullary differentiation is absent.

• High-resolution USG, it allows visualization of
numerous cylindrical cysts in the medulla and
cortex, which represent ectatic collecting
ducts.
 Rupture of kidney
• One of the complication of renal cyst
• Signs of ruptured kidney cyst
1. Pain in the back, sides, abdomen and hips
2. Septicemia (If the fluid in the cysts is infected)
3. Hemorrhage
1. Ultrasound- showed a fistulous tract running
between the renal cyst and the abdominal
wall

1. CT Scan- collection of pus in the perinephric

space
2. loss of the fat plane between the mid-pole of
the right kidney and the postero-lateral
abdominal wall
 Rupture of urethra
• Causes:
1.Pelvic fractures, mostly as a result of motor
vehicle accidents
2.Simple stretching
3.Partial rupture
4.Complete disruption
Radiographic examination

- Dynamic retrograde urethrography is the gold standard for evaluating

urethral injury
- If posterior urethral injury is suspected, a suprapubic catheter is
inserted and a cystogram performed to exclude bladder-neck
injuries
- Simultaneous cystogram and ascending urethrogram can be carried
out later to assess the site, severity and length of injury as well as
the function of the bladder neck
 Benign prostatic hyperplasia
• Benign enlargement of the prostate gland that
occurs commonly in aging men
• Histological changes include stromal and
epithelial hyperplasia in the periurethral zone
• This will compress the prostatic urethra and
obstruct urinary flow
• It depends on testosterone
1. UFEME
2. Urine culture (to exclude infection)
3. Serum PSA, prostate specific antigen (to exclude cancer)
4. Renal function test (to exclude renal failure)
5. KUB (to exclude stone)
6. Transabdominal USG or direct chateterization to assess
residual urine volume
7. Uroflowmetric findings of diminished flow rate and
prolonged voiding or urodynamic evidence of low flow rate
despite high intravesical pressure
8. Cystourethrascope ( to assess visual obstruction, diverticuli
formation, bladder calculi)
9. Transrectal ultrasonography (to demonstrate enlargement
and allow estimation of the volume of prostatic tissue and
biopsy if a significant risk of cancer exist
 Medications
Examples:
1. Quinine
2. Rifampin
3. Phenytoin
Principles of Management
Haematuria
 Traumatic causes
1. Conservative Treatment:
-resuscitation
-bed rest, observation
-must be explored if haematuria/loin swelling

is increases
2. Surgical Exploration: when massive blood loss
as tamponading effect, nephroctomy
 Stone
1. Conservative treatment - if the stone is small
2. Treat the pain - NSAIDS (diclofenac,
indomethacin), muscle relaxants
3. Extracorporeal shock-wave lithotripsy (EWSL)
- break up the fixed, big stones
4. Pre-operative treatment - antibiotics
5. Operations (PCNL) – unpassable big stone
6. Prevent of recurrences - urine of stone formers
should be investigated
PCNL EWSL
 Infections
1. Prevent growth of organisms - administer
broad spectrum antibiotics, alkalinisation
2. Treat the pain - morphine-like analgesics
3. Surgical treatment
4. Kidney drainage, pus is aspirated
5. Antituberculous Chemotherapy, followed by
operative treatment
 Tumors
1. Surgical removal of the tumour – Nephrectomy,
Cystectomy, nephroureterectomy, endoscopically
2. Radiotherapy, chemotherapy
3. Immunotherapy

4. Benign Prostatic Hyperplasia –

a) conservative treatment - include - watchful waiting with
fluid restriction, reduction of caffeine intake
b) drugs – those who are worried of erectile dysfunction after
TURP- alpha blockers, 5a-reductase
c) operative treatment – Open & Closed Prostatectomy
(TURP)
Open Prostectomy Closed Prostectomy
(TURP)
- Transvesical / retropubic
- May damage ext. sphincter - more precise
- Long hosp. - Short hosp