Makindo Medical Notes.com

Related Subjects: Acute Kidney Injury

The main concern is clot retention and obstruction. This will need a 3-way catheter. All patients need to be considered for cystoscopy and renal tract imaging to exclude cancer or other causes

About

• Macroscopic haematuria (red colour urine): can be confused with bile pigments, porphyrins, Hb and myoglobin. Confirm haematuria by microscopy
• Microscopic haematuria: >3–5 RBCs per high-power field on microscopy
• Heavy bleeding + clots can cause anaemia, low BP and urinary tract obstruction
• Bleeding can be a sign of disease including cancer in older patients
• Refer for advice from Urologists. Cancer common in over 60s

Top tips

• In patients with a solitary kidney, a much lower threshold must be adopted for inpatient investigation, treatment and early referral to the urology team.
• In macroscopic haematuria, that the passage of clots down the ureter may induce ureteric colic in the same way as the passage of a stone
• Following trauma to the pelvis the presence of blood at the meatus of the penis or perineal bruising may suggest urethral injury; where this is suspected, or in cases of bladder injury or fractured penis, a urethrogram should be obtained before catheterisation is attempted, and early referral should be made to the urological team

Causes

• Urinary tract malignancy: kidney, renal pelvis, ureter, bladder, prostate, urethra
• Urinary calculi, Urinary tract infection, Schistosomiasis
• Trauma: penetrating or blunt
• Benign prostatic hyperplasia
• Exercise-induced haematuria (mauy be seen with IgA nephropathy )
• Haemorrhagic cystitis, Endometriosis
• Nephrological disease: IgA nephropathy, glomerulonephritis
• Postprocedural bleeding-for example, transurethral surgery
• Bleeding disorders, anticoagulation therapy above therapeutic range
• Arteriovenous malformation/angiomyolipoma

Other conditions that may discolour the urine

• Menstruation, Jaundice
• Ingestion of foodstuffs (beetroot, red cabbage)
• Dyes (paprika, other food colourings)
• Drugs (Rifampicin, Metronidazole, Nitrofurantoin, warfarin, phenytoin)
• Some gram negative bacteria (possessing indoxyl sulphatase)
• Rhabdomyolysis
• Rare metabolic disorders (porphyria, alkaptonuria)

Clinical

• Has patient passed clots. Was there any difficulty
• Fever, urgency and urinary incontinence, which are suggestive of UTI.
• Occupational history, exposure to chemicals and smoking, as these predispose to risks of TCC of the bladder.
• History of bleeding disorders or use of anticoagulants
• History of trauma - avoid catheter if pelvic fracture
• Sore throat/upper respiratory tract infection in young patients may be suggestive of IgA nephropathy.
• Schistosomiasis is a risk factor for SCC of the bladder
• Presence of a palpable bladder, which may be indicative of acute or imminent urinary retention.
• Careful palpation for a tumour mass (potential sites include renal, bladder or gynaecological origin).
• In females, a vaginal examination should be performed to ensure that the blood comes from the urethra rather than the vagina. In males, the external genitalia should be examined.
• In both sexes, a digital rectal examination should be performed to exclude tumour masses either in the prostate or in the pouch of Douglas.
• Macroscopic haematuria: is it Rose, Claret. The presence or absence of clots should also be noted.

Investigations

• FBC, assess HB if low, WCC for infection and platelets
• U&E eGFR: acute renal failure. May be post-renal and obstructive
• Dipstick urine test should be performed in the ED. Detects micro/macroscopic haematuria. Those with microscopic haematuria will also require follow-up, but this can be safely arranged via their general practitioner. Send MSSU
• Beta-HCG if fertile female. PSA in older men.
• Clotting: exclude coagulopathy or anticoagulants. Warfarin check INR
• Group and save (with or without cross-match)
• Radiological imaging: Kidney, ureters, bladder (KUB) x-ray is easily available and simple to perform and either intravenous urography (IVU) or ultrasound scanning (USS) or CT-KUB should be performed in this group of patients.
• USS is a non-invasive test but may be limited by its operator dependence. In combination with plain KUB radiographs, USS by a radiologist has been shown to have a diagnostic accuracy comparable to that of IVU.
• IVU has a number of contraindications: asthma, use of metformin, renal impairment, seafood/contrast allergy, hepatic impairment and pregnancy. This may limit the usefulness of this investigation as a first-line choice.
• CT-KUB may be a useful second-line investigation in those patients with normal first-line tests and persistent haematuria. The “pick-up rate" for current first-line radiological investigations is high, particularly when the radiological tests are reported by specialist uroradiologists.
• Flexible cystoscopy: all patients with macroscopic haematuria should undergo a flexible cystoscopy. This is a minimally invasive and outpatient procedure. Can directly visualise the urethra and bladder. Can take biopsies.

Referrals to nephrology

• Significant proteinuria (greater than 2+)
• abnormal renal function (eGFR < 60mL/min/1.73m2
• +/- imaging findings suggestive of primary renal disease.
• IgA nephropathy, Alport's Syndrome, Thin Membrane Disease
• Acute glomerulonephritis, Adult polycystic kidney disease, Vasculitis

Three way catheter

• Balloon inflation port may take 20-30 ml water which it is important tor remove when removing catheter
• Bladder urine drainage
• Bladder irrigation fluid port can use 50 ml aliquots of sterile water
• Usually large 22-24 french

Management

• Indications for admission include clot retention, cardiovascular instability, uncontrolled pain, sepsis, acute renal failure, coagulopathy, severe comorbidity, heavy haematuria or social restrictions.
• It is important to ensure free drainage of urine. Clot retention is a hazard. Patients should be asked about the presence of clots in the urinary flow, the size of any clots seen, and the ease, or difficulty, with which these were passed. Small clots that easily pass need not be a bar to outpatient management if mobile, sensible and have the ability to return for further assistance if clot retention occurs. Discharged patients should drink plenty of clear fluids and return for further medical attention if the following occur: clot retention, worsening haematuria despite adequate fluid intake, uncontrolled pain or fever, or inability to cope at home
• Often a few small clots will be seen in the stream, particularly during the first few voidings of the day, as urine has accumulated in the bladder overnight, allowing clots to form. These small clots will frequently be easily passed and clear during the course of the day as the patient drinks fluid.
• If clot retention is present, the treatment of choice is the insertion of a three-way Foley catheter, in the same manner as a standard two-channel catheter. The additional channel allows irrigation fluid to be passed through the bladder, clearing clots from the site of bleeding. Inserting a two-channel Foley catheter is a much less satisfactory solution, but may provide an adequate relieving measure if no three-way catheter is available. However, it must be of adequate size to allow both drainages of clots and intermittent irrigation using a catheter syringe (ideally size 16Ch or above). It is important to remember that a two-channel catheter will often require changing to a three-way catheter at a later point, as two-channel Foley catheters are prone to blockage and do not allow constant irrigation to take place. A change of catheter can be extremely uncomfortable for the patient, particularly if the initial catheterisation process was difficult.
• In patients with a suprapubic catheter already in situ, irrigation can be commenced down the suprapubic catheter and out through a two-channel urethral catheter of adequate size. If it proves impossible to pass a urethral Foley catheter, the temptation to site a suprapubic catheter in the acute stage or perform aspiration of the bladder should be resisted, as seeding of a bladder tumour to the abdominal wall may occur. It may, on rare occasions, ultimately prove necessary to perform a suprapubic catheterisation in this onerous situation, but this is a decision best taken by a urologist, having exhausted all means of inserting a urethral catheter.
• If the patient has a coagulopathy that may need urgent management. Risk assess holding or reversing anticoagulants.
• If bleeding fails to settle then the issue becomes for urology to manage. Surgery may be needed. Contact and take advice from urology. Replace blood by transfusion if needed. Manage any bleeding issue.
• Tranexamic acid is generally avoided as it may cause clot retention

References

• Management of macroscopic haematuria in the emergency department
• Oxford guidelines on Haematuria

Revisions