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Evaluation of Microscopic Hematuria

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Evaluation of Microscopic Hematuria Gil C. Grimes, MD December 17 2002 Case HPI 48 yo male Right sided back pain for 3 weeks Some radiation to groin Recent increase ... – PowerPoint PPT presentation

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Title: Evaluation of Microscopic Hematuria


1
Evaluation of Microscopic Hematuria
  • Gil C. Grimes, MD
  • December 17 2002

2
Case
  • HPI 48 yo male
  • Right sided back pain for 3 weeks
  • Some radiation to groin
  • Recent increase in physical activity
  • Tilling a field in an old tractor

3
Case
  • PMH
  • Seasonal allergies
  • Depression in remission
  • PSH
  • Tonsillectomy
  • Social
  • Tobacco one pack per day for 18 years
  • Alcohol rare
  • Drugs negative

4
Case
  • Meds
  • No Rx
  • No OTC
  • No herbals or vitamins
  • Fam Hx
  • CAD, Fibromyalgia
  • ROS
  • No N/V/F/NS/Wt loss/Dysuria/Hematuria/ED

5
Case
  • Physical
  • 118/66 T-97.9 P 84 Wt 202
  • Gen- NAD WDWN
  • CV- RRR w/o M/C/T, no Bruits
  • Chest- CTAP
  • ABD- NTND BS, No HSM
  • BACK- no CVA tenderness, mild paraspinous
    tenderness at L5
  • GU- normal circ male no hernia

6
Case
  • Labs
  • UA 1.025, pH 6.0
  • Trace ketone
  • Bili positive
  • Blood 2
  • RBC 13-19
  • WBC 0-1
  • LE Neg
  • Nitrite Neg
  • Culture Negative

7
What is Microscopic hematuria?
  • 2-3 RBC per HPF or gt5 RBC
  • Guideline settled on 3 RBC per HPF on 2 of 3
    specimens
  • Hedge low risk patients
  • Freshly voided clean catch midstream specimen (1)
  • Dipstick
  • Sensitivity 91-100
  • Specificity 65-99 (2,3)
  • Confirm all dipstick results with micropscopy

8
Microscopy
  • Chamber count
  • Resuspension of sediment
  • This is easier
  • Semiquantitative
  • Centrifuge 10 cc urine 5 minutes 2000 RPM
  • Discard supernatent
  • Resuspend in 0.5-1.0 mL of urine

9
Risk factors (1)
  • Smoking history
  • Occupational exposure to chemicals or dyes
    (benzenes or aromatic amines)
  • History of gross hematuria
  • Age gt40 years
  • History of urologic disorder or disease
  • History of irritative voiding symptoms
  • History of urinary tract infection
  • Analgesic abuse
  • History of pelvic irradiation

10
Prevalence
  • 9-18 individuals with hematuria
  • Young Men 18-33 tested yearly for 15 years (4)
  • 1000 patients
  • 38.7 had one episode
  • 16.1 had two episodes (in any 5 year period)
  • One case of transitional cell cancer

11
Causes
  • Life threatening (1)
  • Bladder, Renal cell, Prostate cancer
  • Ureteral or Renal transitional cell carcinoma
  • Metastatic cancer
  • Uretheral and penile cancer
  • Renal lymphoma
  • Abdominal aortic aneruysm

12
Causes
  • Significant requiring treatment
  • Renal, Ureteral, or Bladder calculus
  • Vesicoureteral reflux
  • Bacterial cystitis
  • Ureteropelvic junction obstruction
  • Renal parenchymal disease
  • Symptomatic BPH
  • Uretheral stricture or meatal stensosis
  • Bladder papilloma
  • Mycobacterial cystitis
  • Renal artery stenosis
  • Renal vein thrombosis

13
Causes
  • Significant requiring observation
  • Radiation cystitis
  • Bladder diverticulum
  • Atrophic kidney
  • Bladder neck contracture and phimosis
  • Interstitial or eosinophilic cystitis
  • Asymptomatic BPH and prostatitis
  • Papillary necrosis
  • Renal ateriovenous fistula
  • Renal contusion
  • Polycystic kidney disease
  • Cystocoele, Ureterocele
  • Neurogenic Bladder

14
Insignificant
  • Uretherotrigonitis
  • Renal cyst
  • Duplicated collecting system
  • Prostatic calculus
  • Bladder neck and Uretheral polyps
  • Bladder varices or telangictasia
  • Uretheral caruncle
  • Pseudomembranous trigonitis
  • Uretheritis
  • Pelvic kidney
  • Caliceal Diverticulum
  • Exercise Hematuria
  • Scarred kidney Trabeculated bladder

15
Evaluation
16
Evaluation
17
Evaluation
18
Imaging
  • Intravenous urography
  • Considered by many to be best initial study for
    evaluation of urinary tract
  • Widely available and most cost-efficient in most
    centers
  • Limited sensitivity in detecting small renal
    masses
  • Cannot distinguish solid from cystic masses
  • further lesion characterization by
    ultrasonography, computed tomography or magnetic
    resonance imaging is necessary
  • Better than ultrasonography for detection of
    transitional cell carcinoma in kidney or ureter

19
Imaging
  • Ultrasonography
  • Excellent for detection and characterization of
    renal cysts
  • Limitations in detection of small solid lesions
    (lt3 cm)

20
Imaging
  • Computed tomography
  • Preferred modality for detection and
    characterization of solid renal masses
  • Detection rate for renal masses comparable to
    that of magnetic resonance imaging, but more
    widely available and less expensive
  • Best modality for evaluation of urinary stones,
    renal and perirenal infections, and associated
    complications
  • Sensitivity of 94 to 98 for detection of renal
    stones, compared with 52 to 59 for intravenous
    urography and 19 for ultrasonography

21
Followup
22
Referances
  1. Grossfield GD, Litwin MS, Wolf JS, Hricak H,
    Shuller CL, Agerter DC, Carroll PR Evaluation of
    asymptomatic microscopic hematuria in adults
    the American Urological Association best practice
    policy-part I Definition,detection, prevelence,
    and etiology Urology 57 599-603, 2001
  2. Sutton JM, Evaluation of Hematuria in adults
    JAMA 2632475-2480, 1990
  3. Corin HL, and Silverstein MD, Micropscopic
    hematuria Clin Lab Med 8601-910, 1988
  4. Froom P, Ribak J, Benbassat J. Significance of
    microhemturia in young adults BMJ 28820-22, 1984
  5. Grossfield GD, Litwin MS, Wolf JS, Hricak H,
    Shuller CL, Agerter DC, Carroll PR Evaluation of
    asymptomatic microscopic hematuria in adults
    the American Urological Association best practice
    policy-part Ii Patient evaluation, cytology,
    voided markers, imaging, cystoscopy, nephrology
    evaluation, and follow-up, Urology 57 604-610,
    2001
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