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Haematuria 227
CASE 5.2 –
‘I have to go quite frequently and also have blood in my
urine’
A1: What is the likely differential diagnosis?
Urinary tract infection (UTI)
Carcinoma in situ of the bladder
Interstitial cystitis
Bladder stones or lower ureteric stone
A2: What issues in the given history support/refute a particular diagnosis?
Dysuria and frequency
Suprapubic pain or discomfort, common to patients with cystitis
Feeling an incomplete emptying of bladder, with u-like symptoms
A3: What additional features would you seek to support a particular
diagnosis?
Recurrent infections often have an underlying predisposing cause. They are common in sexually active
women but also occur in older postmenopausal women prone to constipation and immobility. Bladder
outow obstruction typically presents with a reduced urine ow, frequency and incomplete bladder
emptying, with a high post-micturition residual volume. A history of diabetes, uterine prolapse, recent
urethral instrumentation, indwelling long-term urethral catheters or stents and urinary stone disease is
relevant.
Ureteric reux of urine is another cause of re-infection and may be associated with an ascending
infection (pyelonephritis), which typically presents with loin pain, fever and being systemically unwell.
A4: What clinical examination would you perform and why?
General examination to assess sepsis and dehydration
Abdominal examination for masses or palpable bladder
Vaginal examination for prolapse (in men a rectal examination to assess the prostate)
A5: What investigations would be most helpful and why?
Dipstick:
Leukocyte esterase test: detects pus cells in the urine
Nitrate reductase test: detects bacteria that reduce nitrate to nitrite (specicity of >90 per cent
but sensitivity is variable at 35 to 80 per cent)
Urine microscopy and culture: a colony count of 100 000/cc is used to dene infection and to identify
organism and antimicrobial sensitivity. It is important to note that signicant infection may exist even
with a colony count of 1000/cc and a midstream urine specimen free of contamination is essential to
aid diagnosis.
Urine cytology: this is particularly useful in the presence of storage lower urinary tract symptoms in
the context of recurrent UTIs to rule out transitional cell carcinoma (TCC) of the urinary bladder.
Plain radiograph of the abdomen: this identies renal tract calcication.
Ultrasonography of renal tract: this assesses renal cortex thickness and scarring (common after
recurrent ascending infections) and measures post-micturition residual in the bladder.
Contrast CT urography or intravenous urogram (IVU): this denes the anatomy of renal tract and
stone disease.
Cystoscopy: this is performed if persistent haematuria is present or there are signicant storage lower
urinary tract symptoms.
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228 Urology
Micturating cystourethrogram: this is indicated only if renal scarring is noted and clinical features
suggest ureteric reux.
A6: What treatment options are appropriate?
It is important to classify UTIs into uncomplicated, complicated or recurrent ones. An uncomplicated
UTI is one that occurs in a healthy woman with a structurally and functionally normal urinary tract. This
is often treated empirically with a short course of broad-spectrum antibiotics followed by appropriate
treatment based on urine cultures, which often take 2 to 3 days. Further investigations are needed if
there are three episodes of cystitis in women and a single episode of infection in men.
A complicated urine infection is considered if factors like male gender, childhood UTI, pregnancy,
immunocompromised, elderly and indwelling foreign body (e.g. catheter) or abnormal urinary tract are
present. A recurrent infection is often due to resistant organisms and requires a modied approach,
often with advice from a microbiologist.
Treat predisposing causes such as obstruction (urethral dilatation if the urethra is stenosed),
correction of uncontrolled diabetes, treatment of stone disease and prolapse. Bacterial adherence to
the urothelium or vaginal epithelium is an essential step in initiation of UTI. This is determined by several
bacterial adhesins (e.g. pili on surface of bacteria) that may be on the surface of urinary pathogenic
Escherichia coli that bind to the epithelial cells. The adhesive characteristics of the epithelial cells of
women susceptible to infections and pathogenic bacteria are associated with increased risk of infection.
Bladder wall epithelium permeability and adherence is reduced by exogenous glycosaminoglycans (GAG)
(e.g. hyaluronic acid).
CASE 5.3 –
‘There is blood on testing my urine’
A1: What is the likely differential diagnosis?
Causes of asymptomatic microscopic haematuria by incidence are as follows:
Benign essential haematuria (37 per cent)
Benign prostatic hyperplasia (BPH) (24 per cent)
UTI (27 per cent)
Urinary stone disease (6 per cent)
Bladder tumour (2 per cent)
Renal cyst (1.5 per cent)
Renal tumour (0.5 per cent)
A2: What issues in the given history support/refute a particular diagnosis?
A nephrological cause for microscopic haematuria is common in those aged under 40 years and may be
associated with hypertension and proteinuria.
A3: What additional features would you seek to support a particular
diagnosis?
Benign causes:
UTI
Trauma, vigorous exercise-induced haematuria, menstruation and sexual activity
Nephrological cause:
Is there young-onset hypertension?
Is there proteinuria?
Renal insufciency
Red cell casts or dysmorphic red cells in urine
Risk factors for signicant disease with microscopic haematuria:
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Haematuria 229
Smoking
Occupational exposure to chemicals or dyes (benzenes or aromatic amines)
History of urological disease or storage lower urinary tract symptoms (LUTS) and UTI
Analgesic abuse
History of pelvic irradiation
A4: What clinical examination would you perform and why?
Examine for abdominal masses and any pelvic masses, including assessment of prostate.
A5: What investigations would be most helpful and why?
Urine microscopy: rules out infection
Urine phase contrast microscopy: for dysmorphic erythrocytes indicating glomerular source of
bleeding
Urine cytology: identies transitional cell carcinoma
CT urography/IVU or ultrasonography: for assessing the anatomy of the renal tract and collecting
system
Renal biopsy: rarely indicated and usually supervised by a nephrologist
Cystoscopy: the ‘gold standard’ investigation for the bladder
A6: What treatment options are appropriate?
The incidence of underlying urological malignancy in those presenting with microscopic haematuria is 5
to 7 per cent; it is therefore important to investigate all patients with microscopic haematuria. The risk
of underlying malignancy increases with age, and those over 55 years with microscopic haematuria are
referred as urgent 2-week referrals.
A patient with asymptomatic microscopic haematuria, proteinuria and hypertension who is aged
under 40 years is likely to have a glomerular cause for the microscopic haematuria. Immunoglobulin IgA
nephropathy is the most common cause found on renal biopsy when no urological cause is noted.
Glomerular causes:
Age <50 years
IgA nephropathy
Thin basement membrane disease
Alport’s disease (hereditary nephritis)
Mild focal glomerulonephritis (GN)
Age >50 years
IgA nephropathy
Alport’s disease (hereditary nephritis)
Mild focal GN
Referral to a nephrologist is recommended if risk factors for underlying nephrological cause are present.
Investigation of asymptomatic microscopic haematuria may also reveal an underlying urological
pathology such as urinary stone disease, infections, BPH or urological cancer that is treated appropriately.
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230 Urology
OSCE Counselling case
OSCE COUNSELLING CASE 5.1 –
‘How do I prevent recurrent urinary
infections?’
Re-infection with the same strain of the organism is more common than persistence of the urinary
pathogen. Colonic or perineal ora are the reservoir for these re-infecting strains. A relapse within 7
days of treatment usually indicates failure to eradicate the infection. In contrast, if bacteriuria is absent
14 days after infection and followed by a recurrence of infection, this is likely to be a re-infection. It is
therefore essential to treat every infection with the appropriate antibiotic for an adequate length of time
to prevent relapse.
General measures to prevent infections include adequate uid intake, appropriate frequent voiding
and postcoital micturition. It is good to achieve a short voiding interval and high ow rate, drinking
large amounts of uid to dilute the bacteria.
Regular intake of cranberry juice has been shown to be helpful in reducing recurrent infections.
Although not proven, excessive scrubbing and cleaning may damage genital skin and vaginal mucous
membranes by excessive douching and reduce the normal barrier to infection.
Wiping the anus from front to back after passing stools should be encouraged as general hygiene
principles.
Investigation and treatment should consider the predisposing factors such as stones, urethral
diverticulum and diabetes.
REVISION PANEL
Bladder cancer is one of the most common causes of visible painless haematuria.
Transitional cell cancer is the most common form of bladder cancer with squamous and
adenocarcinoma.
Supercial or non-muscle invasive bladder cancer is managed by endoscopic resection followed
by intravesical chemotherapy. Recurrences are managed by endoscopic surveillance and by
intravesical chemotherapy.
Muscle invasive bladder cancer is managed by radical treatment with either radical cystectomy or
radical radiotherapy to the bladder.
Uncomplicated UTI is often in healthy women with a structurally and functionally normal urinary
tract. It is often treated empirically with a short course of antibiotics from 1 to 3 days.
Complicated UTI is often in men, children and pregnant women or is associated with abnormal
urinary tract, immunocompromised or with indwelling foreign bodies. This often requires a longer
course of antibiotics.
Recurrent UTIs are associated with a range of causes like atrophic vaginitis, abnormal urinary tract
or poor bladder emptying. Bacterial adherence is associated with increased virulence and altering
the adhesins.
Microscopic haematuria in those <40 years of age is usually due to nephrological causes.
Microscopic haematuria may be due to underlying malignancy and the risk increases with age and
hence in >55 years of age is referred as a 2-week referral.
Microscopic haematuria is investigated with lower tract cystoscopy and upper tract imaging.
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Stone disease 231
STONE DISEASE
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What issues in the given history support/refute a particular diagnosis?
Q3: What additional features would you seek to support a particular diagnosis?
Q4: What clinical examination would you perform and why?
Q5: What investigations would be most helpful and why?
Q6: What treatment options are appropriate?
CASE 5.4 –
‘I have pain in my loin’
A 45-year-old woman presents to her GP with signicant loin pain associated with nausea and vomiting.
She has had a similar episode before and has required an operation to remove a stone in her ureter.
CASE 5.5 –
‘I have recurrent infection and a dull ache in my loin’
A 35-year-old woman presents with dysuria and passing stones/debris in her urine. She also has a dull
loin ache. She has had recurrent UTIs that her GP has been treating with antibiotics for the last 2 years.
She has two children and is a smoker.
CASE 5.6 –
‘I have a fever and quite severe pain in my loin’
A 37-year-old businessman had quite severe pain in his loin with a high temperature and was feeling
unwell.
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232 Urology
OSCE Counselling cases
OSCE COUNSELLING CASE 5.2 –
‘How do I prevent recurrent stone
formation?’
A 45-year-old woman presents with a 4-year history of recurrent urine infections. She has had two normal
deliveries and has a normal menstrual cycle. Clinical examination and investigations are unremarkable.
Q1: What general measures would you recommend to reduce urine infections?
OSCE COUNSELLING CASE 5.3 –
‘How do I counsel for extracorporeal
shock wave lithotripsy (ESWL)?’
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Stone disease 233
Key concepts
PRESENTATION
Renal pain is usually felt in the loin, sometimes spreading to the umbilicus and testis.
Obstruction of the lower ureter may lead to bladder irritability or pain in the scrotum, penile tip or
labia majora. Stones can also cause a recurrent painful desire to micturate, with only a little urine
passed each time (strangury).
PREDISPOSING FACTORS FOR STONE FORMATION
Low urine volume can contribute to stone formation.
Metabolic disorders of calcium: absorptive hypercalciuria is the most common abnormality detected
in patients with calcium oxalate stones and is present in about 60 per cent of such patients. It is
caused by an altered intestinal response to vitamin D, leading to increased absorption of calcium and
hypercalcaemia, and decreased parathyroid hormone (PTH) secretion.
Elevated urinary excretion/concentration of oxalate, calcium or uric acid; decreased excretion of
inhibitors of stone growth; increase in urinary pH all contribute to stone formation.
BASIC ADVICE AND TREATMENT FOR RECURRENT STONE FORMERS
The most important risk factor is urine volume: if the volume is doubled, the risk of forming further
stones is reduced by a factor of four.
CRYSTALLINE COMPOSITION OF RENAL CALCULI
Calcium oxalate (40 per cent)
Calcium phosphate (15 per cent)
Mixed oxalate/phosphate (20 per cent)
Struvite (15 per cent)
Uric acid (10 per cent)
Miscellaneous stones 15 per cent (cystine, rare metabolites, drugs etc.)
Analysis of a stone to determine composition can be useful in the management of patients with renal
stones.
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234 Urology
Answers
Clinical cases
CASE 5.4 –
‘I have pain in my loin’
A1: What is the likely differential diagnosis?
Ureteric colic
Acute appendicitis
Diverticulitis
Ruptured aortic aneurysm
Salpingitis
Pyelonephritis
A2: What issues in the given history support/refute a particular diagnosis?
History is consistent with ureteric colic (e.g. radiating loin to groin pain). Pain is often continuous. Pain
from obstruction to upper or mid ureteric stone may cause pain on the right side in keeping with
right iliac fossa pain mimicking acute appendicitis. Pain from mid-ureteric obstruction on the left side
causes pain in the left iliac fossa mimicking acute diverticulitis. Pain from lower ureteric obstruction
may cause pain to the tip of the penis or labia and often may have frequency and urgency.
Haematuria on urinalysis and persistent pain are recorded.
A3: What additional features would you seek to support a particular
diagnosis?
History suggestive of a ureteric colic may be associated with fever in pyelonephritis. The presence of
obstruction with infection in a renal unit leads to severe systemic sepsis and is particularly important
to rule out the presence of hydronephrosis. The presence of hydronephrosis may suggest obstruction
and drainage of the renal unit with either a nephrostomy or insertion of a ureteric stent may be
required. Ureteric obstruction leads to nephron loss in the affected renal unit. The presence of infection
accelerates the nephron loss extremely rapidly and drainage of the renal unit is essential to reduce
nephron loss.
Criteria for admission:
Pain not adequately controlled
Temperature >37.5°C and signs of sepsis/obstructed kidney/unstable patient
Unable to tolerate diet and uids
Deranged urea and electrolytes (U&Es) and raised white blood cell count (WCC)
A4: What clinical examination would you perform and why?
A ruptured abdominal aortic aneurysm may cause loin pain and may mimic a ureteric colic particularly
in older patients and hence a high index of suspicion needs to be maintained. Therefore, an abdominal
examination for pulsatile mass or aneurysm is essential. Identication of bruising in the loin is associated
with retroperitoneal bleeding (e.g. ruptured aortic aneurysm). Clinical examination reveals renal
tenderness and renal mass. Pain, renal mass and haematuria may be associated with a renal tumour.
A5: What investigations would be most helpful and why?
Urine microscopy is used to rule out infection.
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Stone disease 235
IVU shows 90 per cent of stones which are radio-opaque. It is useful to assess the anatomy
and function of the urinary tract and also identify the size of stone and the degree and level of
obstruction.
Computed tomography (helical/spiral CT) is the current ‘gold standard’ for imaging abdominal pain
and can identify ureteric calculi and other causes of abdominal pain. It has a sensitivity and specicity
of 96 per cent and 100 per cent, respectively.
A6: What treatment options are appropriate?
Symptomatic treatment, analgesia, antibiotics, drainage of kidney using either a percutaneous
nephrostomy or ureteric JJ stent insertion. Prompt drainage of the kidney (e.g. percutaneous
nephrostomy/JJ stent insertion) is indicated in a patient with an obstructed,
infected upper urinary
tract, impending renal deterioration,
intractable pain or vomiting, anuria or high-grade obstruction
of a
solitary or transplanted kidney.
CASE 5.5 –
‘I have recurrent infection and a dull ache in my loin’
A1: What is the likely differential diagnosis?
Pelviureteric junction (PUJ) obstruction
Urinary stone disease
Ureteric reux disease
Xanthogranulomatous
pyelonephritis (XGPN)
Renal tract tuberculosis (TB)
A2: What issues in the given history support/refute a particular diagnosis?
Recurrent UTIs, fever, passing grit and stones
A3: What additional features would you seek to support a particular
diagnosis?
A history of loin pain after increased uid intake and alcohol would suggest obstruction of the PUJ.
Xanthogranulomatous pyelonephritis represents an unusual suppurative granulomatous reaction to
chronic infection, often in the presence of chronic obstruction from a calculus, stricture or tumour, and
may present with symptoms of long-standing inammation and loin pain in patients with urinary stone
disease. Both CT and ultrasonography show areas of pus and necrotic debris within the kidney.
Renal tract TB, although uncommon in the United Kingdom, should be considered. Pulmonary TB
precedes the development of genitourinary TB.
A4: What clinical examination would you perform and why?
Abdominal examination should be performed to rule out renal mass. Loin bruising or swelling may
suggest retroperitoneal collection of blood or pus. Pus may tract along the psoas major and present as a
collection in the groin.
A5: What investigations would be most helpful and why?
Radiograph of the abdomen: identies renal tract calcications
Ultrasonography: hydronephrosis and dilatation of renal pelvis
IVU: function and anatomy of the renal tract
CT urography: will identify renal anatomy
Technetium-99m-labelled mercaptoacetyl triglycine (MAG-3): identies the presence of underlying
obstruction to the kidney and split function of the kidney
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236 Urology
A6: What treatment options are appropriate?
Staghorn calculi require a multimodal approach to their treatment and often need more than one
procedure to ensure complete removal, which is necessary because residual stone fragments quite
rapidly form a nidus for further stone formation.
Struvite stones are invariably associated with urinary infections – specically, the presence of urease-
producing bacteria, including Ureaplasma urealyticum and Proteus spp. (most common). These lead to
the hydrolysis of urea into ammonium and hydroxyl ions, resulting in an alkaline urine. The resultant
increase in ammonium and phosphate concentrations combined with the alkaline urine (pH > 7.2) are
necessary for struvite and carbonate apatite crystallization.
Treatment includes antimicrobials to reduce infection, and urinary acidifying agents to reduce stone
formation.
A combination of extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy
(PCNL) is used to treat staghorn calculi.
Chemolytic therapy may be used either as a local irrigation via a nephrostomy or as oral agents. The
latter have a role in patients who are not candidates for surgical removal of calculi and are also used
as adjunctive therapy to dissolve residual apatite or struvite calculi and fragments after surgery, or to
achieve partial dissolution of renal calculi to facilitate surgical removal.
Rarely open surgical treatment becomes necessary for the removal of large, complex renal calculi
– either anatrophic nephrolithotomy (bivalving the kidney on the lateral aspect) or pyelolithotomy
(opening the renal pelvis).
CASE 5.6 –
‘I have a fever and quite severe pain in my loin’
A1: What is the likely differential diagnosis?
Upper UTI is likely: pyelonephritis is commonly associated with loin pain, fever and rigors. High-grade
obstruction with infection in an obstructed renal system is commonly associated with severe pain and
rapid septicaemia. In this case the patient will be very sick with hypotension, poor peripheral perfusion
and circulatory collapse.
A2: What issues in the given history support/refute a particular diagnosis?
Stone disease and being unwell with fever would suggest infection and possible obstruction of the
ureter. The presence of hydronephrosis often signies obstruction (although dilatation of the collecting
system may not always be synonymous with obstruction).
A3: What additional features would you seek to support a particular
diagnosis?
History of diabetes or immunosuppression is important as a predisposing factor.
Infection with a gas-forming organism is not uncommon in patients with diabetes – ‘emphysematous
pyelonephritis’. This has a high mortality rate. It is diagnosed radiologically by the presence of gas in the
parenchyma or collecting system and is managed surgically.
A4: What clinical examination would you perform and why?
The patient is usually very ill with fever, chills, ank pain and tenderness, and severe sepsis-related
circulatory collapse.
Infected hydronephrosis is bacterial infection in a hydronephrotic kidney and pyonephrosis is
suppurative destruction of parenchyma of kidney that may lead to nearly total loss of function. Pus may
tract or form and perinephric abscess will form and can even burst in the loin, or a psoas abscess can
form in the femoral triangle.
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