Haematuria And Urinary Tract Infections Notes

Haematuria and Urinary Tract Infections

Causes Of Haematuria

1. In the Kidney

1. Infection
   • Acute glomerulonephritis
   • Tuberculosis
2. Infarction
   • SBE with emboli causing renal infarction
   • Massive haemolysis with acute renal tubular necrosis
   • Mismatched blood transfusion
3. Injury
   • Stab/blunt injury
4. Tumours
   • Wilms’ tumour: Nephroblastoma
   • Hypernephroma: Renal cell carcinoma (RCC)
   • Transitional cell carcinoma (TCC)
5. Stones
6. Polycystic kidney

Read And Learn More: Surgery of Urology Notes

2. In the Ureter:

1. Stone
2. Cancer—rare

3. In the Urinary Bladder:

1. Carcinoma bladder
2. Carcinoma prostate
3. Cystitis
4. Tuberculosis
5. Bilharziasis
6. Stone: Common in school-going children
7. Benign prostatic hyperplasia (BPH)

4. Urethra:

1. Stone

5. Rare Causes:

1. Patients on anticoagulants
2. Sickle cell anaemia
3. Bleeding disorders

History And Examination

1. Age and Sex:

• Young children-Vesical calculus
• Young adults-Renal stones, TB
• Elderly patients-RCC

2. Occupation:

• Aniline dye workers
• Carcinoma bladder

3. Haematuria:

• Bright red
• Lower urinary tract
• Altered blood
• Kidney
• Profuse
• Papilloma
• Small quantity
• Renal cell carcinoma, renal TB, stone
• Beginning of micturition
• Urethral pathology
• End of micturition
• Bladder pathology
• Mixed with urine
• Renal
• Painless haematuria
• Papilloma or carcinoma
• Painful haematuria
• Renal stone, bladder stone

4. General Physical Examination:

• Gross pallor
• Significant blood loss
• Gross pallor with minimal blood loss
• RCC
• Hypertension
• Polycystic kidney
• Bony pains
• Carcinoma (prostate)

5. Abdominal Examination:

• Palpable kidney
• Polycystic kidney, Wilms’ tumour, RCC
• Distended bladder
• Carcinoma prostate, enlarged prostate
• Suprapubic tenderness
• Bladder stone, cystitis
• Craggy epididymis
• Genitourinary TB and beaded vas

6. Rectal Examination:

• Enlarged smooth, firm prostate
• BPH
• Hard irregular prostate
• Carcinoma prostate
• Hard, thickened seminal vesicles
• Genitourinary TB
• Advanced growth infiltrating urinary bladder
• Carcinoma rectum

History And Examination Investigations

1. Urine Examination:

• Worm-like clots
• Growth in the ureter
• Flat disc-like
• Urethra
• Pieces of tumour
• Papilloma of the bladder

2. Urine Microscopy:

• Pus cells
• Urinary tract infection
• Abacterial acid pyuria
• TB
• Malignant cells positive bladder
• TCC or papilloma

Utility of various investigative modalities for evaluation of haematuria:

3. Plain X-ray KUB

• Enlarged kidney
• Polycystic kidney, RCC
• Radio-opaque shadows stones, bladder stone
• Renal stones, ureteric

4. Cystoscopy:

• Growth in the bladder
• Papilloma bladder/TCC
• Inflammation of the bladder
• Cystitis
• Ulcers, hyperaemia, golf-hole ureter
• TB

5. Intravenous Urography:

• Spider leg calyces
• Polycystic kidney
• Irregular calyces
• RCC
• Missing calyces
• TB

6. Ultrasound:

• Enlarged kidney
• Renal cell carcinoma, polycystic kidney, Wilms’ tumour, stones

Hematuria

Haematuria is defined as the passage of blood mixed with urine.

Hematuria Classification:

1. Depending upon whether the blood is seen or not:

1. Microscopic: Not visible to the eye
2. Macroscopic: Visible to the eye

2. Depending upon the site of origin of the blood:

1. Glomerular (renal)
2. Non-glomerular (urological)

Macroscopic or Gross Haematuria:

Urine may vary in colour from red to stale brown or chocolate coloureIt may be associated with clots. The nature of the clots may give a clue to the source or site of bleeding. Serpiginous or vermiform clots indicate bleeding from the kidneys. Amorphous clots suggest bleeding from the lower tract. Most patients with gross haematuria have some pathology in the kidneys or genitourinary tract.

It can be initial, terminal, or throughout the stream. Urethral bleeding usually manifests as the first 10–15 ml of bloodstained urine, which gradually clears. Terminal haematuria usually indicates trigonal irritation (e.g. bladder stone). It is usually associated with dysuria and strangury. Bleeding from the upper urinary tract (kidneys and ureters) is seen throughout the stream as blood mixes with the urine stored in the bladder.

Microscopic Haematuria:

It is defined as the presence of ≥3 RBCs on microscopic examination. It is usually detected incidentally on urine dipstick testing and subsequent microscopic examination. Normal RBC excretion is up to 2 million RBCs/day.

Hematuria Aetiology:

Evaluation: Numerous investigative modalities are available for evaluating haematuri The choice of modality depends on clinical suspicion and important clinical signs.

Ultrasonography: It is noninvasive and less expensive

• Diagnosis of upper or lower urinary tract lesions
  • Stones
  • Tumours
• Hydronephrosis
• Renal parenchymal changes suggest a glomerular cause.
• Ultrasound examination guides towards choosing further investigations.
• Less sensitive for evaluating of ureteral causes of haematuria.

Distinguishing between glomerular and urological causes of haematuria:

Urinary Tract Infections

UTI is an inflammatory response of the urothelium to bacterial invasion that is usually associated with bacteriuria and pyuria.

Bacteriuria is the presence of bacteria in the urine, which is normally free of bacteriIt can be symptomatic or asymptomati

Pyuria is the presence of white blood cells (WBCs) in the urine. It is generally indicative of infection and/or an inflammatory response of the urothelium to the bacterium, stones, or other indwelling foreign body.

Bacteriuria without pyuria is generally indicative of bacterial colonisation without infection of the urinary tract.

Pyuria without bacteriuria warrants evaluation for tuberculosis, stones, or cancer.

Urinary Tract Infections Clinical Features:

Urinary Tract Infections Signs and Symptoms:

Lower tract infections/cystitis:

• Frequency, and/or urgency
• Suprapubic pain
• Haematuria is not common
• Lower tract symptoms are commonly present and usually predate the appearance of upper tract symptoms by several days.

Upper tract infections/acute pyelonephritis:

• Fever with chills
• Flank pain
• Nausea and vomiting
• A renal or perirenal abscess may cause indolent fever and flank mass and tenderness.
• In the elderly, the symptoms may be much more subtle (e.g. epigastric or abdominal discomfort) or the patient may be asymptomatic.
• Patients with indwelling catheters often have asymptomatic bacteriuria, but fever associated with bacteremia may occur rapidly and become life threatening.

Chronic pyelonephritis describes a shrunken, scarred kidney. It is diagnosed by morphologic, radiologic, or functional evidence of renal disease that may be postinfectious but is frequently not associated with UTI.

Classification of UTI:

1. Uncomplicated UTI: It is an infection in a healthy patient with a structurally and functionally normal urinary tract.

2. Complicated UTI: It is associated with factors that increase the chance of acquiring bacteria and decrease the efficacy of therapy. Most of these patients are men.

3. Recurrent UTI: Recurrences of uncomplicated and/ or complicated UTIs, with a frequency of at least three UTIs/year or two UTIs in the last six months.

4. Catheter-associated UTI: CA-UTI refers to UTIs occurring in a person whose urinary tract is currently catheterised or has had a catheter in place within the past 48 hours.

5. Urosepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection originating from the urinary tract and/or male genital organs.

Incidence and Predisposing Factors:

• Nearly 30% of women will have had a symptomatic UTI requiring antimicrobial therapy by age 24, and almost half of all women will experience a UTI during their lifetime.
• The prevalence of bacteriuria in young women is 30 times more than in men.
• The incidence of bacteriuria also increases with institutionalization or hospitalization and concurrent disease.
• Catheter-associated UTIs (CAUTIs) are the most common nosocomial infection.

Predisposing Factors:

1. Pregnancy
2. Patients with spinal cord injuries
3. Diabetes
4. Multiple sclerosis
5. Human immunodeficiency virus (HIV) infection/ acquired immunodeficiency syndrome (AIDS).

Pathogenesis and Bacteriology:

UTIs are a result of interactions between the uropathogen and the host. Successful infection of the urinary tract is determined in part by the virulence factors of the bacteria, the inoculum size, and the inadequacy of host defence mechanisms.

Routes of Infection:

1. Ascending route
2. Haematogenous route
3. Lymphatic route

Urinary Pathogens:

• Most UTIs are caused by facultative anaerobes usually originating from the bowel flora.
• Uropathogens such as Staphylococcus epidermidis and Candida albicans originate from the flora of the vagina or perineal skin.
• E. coli is by far the most common cause of UTIs, accounting for 85% of community-acquired and 50% of hospital-acquired infections.
• Other gram-negative Enterobacteriaceae, causing community acquired UTI, are Proteus and Klebsiella
• Gram-positive E. faecalis and Staphylococcus saprophyticus are responsible for the remainder of most community-acquired infections.
• Nosocomial infections are caused by E. coli, Klebsiella, Enterobacter, Citrobacter, Serratia, Pseudomonas aeruginosa, Providencia, E. faecalis, and S. epidermidis.
• Mycobacterium tuberculosis—do not grow under routine aerobic conditions and may be found during evaluation for sterile pyuria.
• Less common organisms:
  • Gardnerella vaginalis, mycoplasma species, and Ureaplasma urealyticum infect patients with intermittent or indwelling catheters.
  • Anaerobic organisms are frequently found in suppurative infections of the genitourinary tract. The organisms found are usually Bacteroides species, including fragilis, Fusobacterium species, anaerobic cocci, and Clostridium perfringens. The growth of clostridia may be associated with Emphysematous cystitis.
  • Chlamydia

Urinary Tract Infections Investigations:

Principle:

1. Urine and the urinary tract are normally free of bacteria and inflammation.
2. Bacteriuria and WBCs provide a presumptive diagnosis of UTI.
3. The presence of 102 cfu/ml confirms a symptomatic UTI.

1. Urine analysis and urine culture: Sample collection

• Midstream urine
• Prostatic massage to acquire prostatic fluid during suspected prostatitis
• Suprapubic aspiration

2. Imaging is indicated in high-risk patients, including women with febrile infections and most men. Radiologic studies determine acute infectious processes that require further intervention or may find the cause of complicated infections

1. Ultrasonography
2. Computed tomography and magnetic resonance imaging
3. Voiding cystourethrogram
4. Radionucleotide imaging

Principles of Antimicrobial Treatment:

 Haematuria and Urinary Tract Infections Multiple Choice Questions

Question 1. What causes haematuria in bacterial endocarditis?

1. Renal necrosis
2. Renal sepsis
3. Renal infarction
4. Coagulopathy

Answer: 1. Renal necrosis

Question 2. Haematuria in polycystic kidney is due to:

1. Hypertension
2. Renal infarction
3. Renal ischaemia
4. Cyst rupture into the renal pelvis

Answer: 4. Cyst rupture into the renal pelvis

Question 3. Which of the following conditions rarely gives rise to haematuria?

1. Renal stones
2. Renal cell carcinoma
3. Bilharziasis
4. Benign prostatic hypertrophy

Answer: 4. Benign prostatic hypertrophy

Question 4. Palpable renal masses in a 40-year-old hypertensive patient with one attack of haematuria is:

1. Hypernephroma
2. Hydronephrosis
3. Adenomyolipoma
4. Polycystic kidney

Answer: 4. Polycystic kidney

Question 5. Which of the following pathologies is reflected as terminal haematuria?

1. Trigonal irritation
2. Posterior urethral irritation
3. Ureteric irritation
4. Renal irritation

Answer: 1. Trigonal irritation

Question 6. In urinary tract infections due to prostatitis, which is the urinary sample asked for?

1. Initial sample
2. Midstream
3. Last sample
4. After prostatic massage

Answer: 4. After prostatic massage