Algorithm for Haematuria

Transcription

1 Procedure that produces the answer to a question or the solution to a problem in a finite number of steps. Algorithm for Haematuria Helen Forristal MSc (ANP) BSc (Hons) IAUN 2013

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5 Haematuria presence of Red Blood Cells in the urine. Distinctions Macroscopic Microscopic (Cameron 1996) Painful Painless Nephrological Urological Differential Diagnosis Initial Terminal Total

6 Haematuria There is a poor correlation between the degree of haematuria and the severity of any underlying cause. An older person with visible haematuria is more likely to have serious underlying pathology than a younger person with microscopic haematuria and no symptoms. All people with haematuria need further investigation. Diagnostic tests and algorithms used in the investigation of haematuria available at )

7 Haematuria Kidney- Trauma (Blunt Penetrating) Calculi; Tumours : Carcinoma of the Renal Parenchyma; Benign Renal Tumours, TCC Renal Pelvis Angiomyolipoma Infections: TB, Pyogenic Infections Congenital disorders: Polycystic kidney disease, Renal Cysts Bleeding Disorders: haemophilia ; leukaemia, sickle cell disease, Anticoagulation therapy Vascular causes : Renal Emboli, Renal vein thrombosis Interstitial Renal Disease Glomerularnephritis, pyelonephritis, papillary necrosis Bladder Trauma Infections-, TB, Schistomiasis, Stone disease Carcinoma - 90%, TCC, SCC, Adenocarcinoma Radiation Haemorrhagic Cystitis Exercise Induced haematuria Pharmacology - Cyclophosphamide Prostate BPH, Adenocarcinoma 90% Prostatitis Urethra and Penis Trauma Urethral and penile tumours -!% Urethritis

8 Haematuria How is haematuria diagnosed? Clinical Assessment Physical Assessment ( DRE and PV examination) Urine test strip Urinalysis for culture and sensitivity Cytology Laboratory investigations Interventional tests eg. Cystoscopy Radiology investigations

9 Natasha, a 53 year old lady presented during routine follow up with a three week history of macroscopic haematuria, dysuria, frequency, hesitancy, polyuria, incomplete voids, urinary incontinence and abdominal discomfort. This was further aggravated by walking and pain was relieved by simple analgesia. Natasha was diagnosed with asthma 24 years ago but this has not been troublesome. (2 Algorithm). Presently fit, takes alcohol socially and stopped smoking 12 years ago. In 2008 she was diagnosed with a muscle invasive bladder cancer and subsequently received radical radiotherapy which was complete June 2009.

10 Clinical Assessment (1) The initial clinical evaluation should provide indications as to the Cause of haematuria Help to eliminate potential benign causes, for example vigorous exercise, menstruation and trauma. (3 Algorithm). Specific questioning regarding health history (4 Algorithm) with focused physical assessment should lead to a number of possible differential diagnoses. (5- Algorithm). Risk factors for significant disease include: Smoking history Occupational exposure to chemicals History of gross haematuria age over 40 years Urological disease Urinary tract infection Analgesic abuse Pelvic irradiation. (Grossfield et al 2001)

11 Clinical Assessment (2) Common or concerning symptoms such as: Fatigue and weakness Changes in weight Fever, chills, night sweats Pain are non specific symptoms but could be associated with some of the differential diagnoses. (4- Algorithm)

12 Physical Assessment (1) Haemodynamic status Abdominal examination: Natasha was complaining of abdominal discomfort and examination revealed suprapubic tenderness with dullness suggesting incomplete emptying of her bladder possibly indicating cystitis. Usual presentation for pyelonephritis could be the classic triad of fever, costovertebral angle pain, and nausea and/or vomiting. (Burke et al 2009). Renal colic often presents with nausea and/or vomiting with severe colicky pain in ureteral obstruction from renal stone. The kidneys were examined specifically for costovertebral angle tenderness; this was absent but if present would indicate renal infection. Right upper quadrant pain might indicate pancreatitis or cholecystitis. ( Bickley & Szilagyi 2009). Genitalia examination: The genitalia was observed and examined externally to rule out the presence of discharge which may indicate urethritis and assessment of urinary leakage noted. (Burke et al 2009) Skin examination (5 Algorithm)

13 Physical Assessment (2) As many as 50% of patients with muscle invasive bladder cancer may have occult metastasis that become clinically apparent within five years of initial diagnosis. (Steinberg et al 2010). For this reason examination of the thorax and peripheral vascular system (PVS) was conducted. (5 Algorithm) The thorax was inspected. (5 Algorithm) The Peripheral Vascular System (PVS) Regional lymphadenopathy is a risk as Natasha s initial diagnosis was muscle invasive bladder cancer Grade 2, almost 3 years ago. The horizontal and vertical group were assessed but no palpable lymph nodes were identified. All pulses were brisk (2+). ( Bickley & Szilagyi 2009). (5 Algorithm).

14 Physical Assessment (4) Natasha was asymptomatic with no bone pain normal calcium and alkaline phosphate levels; therefore a bone scan was unnecessary. (Steinberg et al 2010). (14-15 Algorithm) An FBC indicating low or borderline Hb may indicate the presence of anaemia, particularly with Bladder Cancer or Haemorrhagic Cystitis. Natasha s haemoglobin was 12g/dl (Steinberg et al 2010) (7 - Algorithm) FBC and U & E s are mandatory especially in the presence of pyrexia and /or single functioning kidney. (Guidelines for Acute Management of first presentation of Renal/Ureteric lithiasis, 2008). (7 - Algorithm). Further specific investigations are necessary to determine definite diagnosis.

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16 Lab Investigation An uncontaminated MSU sample is adequate for use in tests for haematuria. (7 - Algorithm). Transient causes that need to be excluded before establishing the presence of significant haematuria are: UTI, haematuria in association with UTI is not uncommon. UTI is most readily excluded by a negative dipstick result for both leucocytes and nitrites. (8 Algorithm). The presence of haematuria should not be attributed to anti-coagulation or antiplatelet therapy and patients should be evaluated regardless of these medications. BAUS/RA Guidelines (2008). (3 - Algorithm) The presence or absence of clotted blood is not completely helpful in determining the etiology of haemorrhagic cystitis but the presence of long stringy clots suggest upper urinary tract etiology, this can lead to acute retention of urine or near episodes. Basler & Miyamoto (2009). (11 - Algorithm) Proteinuria, elevated U & E s and / or hypertension may indicate renal disease and these patients require a nephrological assessment. (BAUS / RA Guidelines 2008) (6 - Algorithm)

17 CLINITEK Step 1 Completely immerse all reagent areas into fresh, well-mixed, uncentrifuged urine. Dip briefly and remove immediately to avoid dissolving out reagents. Step 2 While removing the strip, run the edge against the rim of the urine container to remove excess urine. Hold the strip in a horizontal position to prevent possible mixing of chemicals from adjacent reagent areas or soiling of hands with urine. Step 3 After the appropriate time, compare test areas closely with the corresponding colour chart on the bottle label or bench reader at the time specified. Hold strip close to colour blocks and match carefully. Always record the results. Step 4 For enhanced convenience and standardisation, use a CLINITEK analyser to read the reagent strip and print the results

18 Urothialisis (1)

19 Urothialisis (2) Urinary stone formation is a common disease with an increasing incidence and prevalence worldwide that appears even more pronounced in industrialised countries Most stones are formed in older patients. However, clinical observations have indicated not only a changing frequency and composition of urinary calculi but also a shift in gender and age related incidences. Rare in children. As in adults, factors implicated in the metabolic syndrome complex such as Obesity Impact of climate change Changing lifestyle Dietary choices are the more probable cause of the increasing incidence and prevalence of urothialsis. Diabetes can also be an independent risk factor for the development of kidney stones. Types of Urothialisis: Calcium containing calculi Calcium Oxalate Calcium Phosphate Uric Acid calculi Cystine Calculi

20 Urothialisis (3) Diagnostic Modalities Thin slice CT stone protocol preferably within 24 hours if acute presentation to confirm diagnosis or for planning of treatment if a stone is confirmed on KUB x-ray. KUB allows 60% visibility compared with > 95% stone identification on CT. (BAUS Section of Endourology, 2008). Cystoscopy to visualise the bladder Retrograde studies may be an additional study to visualise both ureter s to determine the positioning of the stone and feasibility of removing the stone. Blood Analysis, Serum Creatinine and Urea (Algorithm 13) Sequential course of disease condition Urolithiasis (UL) is one of the most common diseases, with approximately 750,000 cases per year in Germany. Strohmaier (2000). Although most patients have only one stone episode, 25 % of patients experience recurrent stone formation. Hesse et al (2003). UL therefore has a significant impact on QoL and socioeconomic factors. Loton et al (2004).

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22 Bladder Cancer Bladder cancer is the 8 th most common malignancy in Ireland 3.5% of all malignant neoplasia 4.7% in males and 2% in females 12% of cancers are diagnosed in females between years compared to 13% in the same age range in men. Ferlay et al (2008). (10 Algorithm). Each year, approximately 331 men and 132 women are diagnosed with a bladder tumour. Incidence rates fell between 1994 and 2003 by 1.3% and 2.4% per annum in women and men respectively. Disease of older people 58% of women and 57% of men are aged over 70 at diagnosis, while only around 6-8% of cases present in those aged under 50. Bladder cancer incidence in men in Ireland is among the lowest in western Europe, while that in women is in the mid-range. However, international comparisons of bladder cancer rates are made difficult by inconsistencies in the coding and classification of these cancers. Underlying Pathological Process Almost all bladder cancers are epithelial in origin. The histological appearance of superficial bladder cancer can either represent papillary cells which include features of dysplasia or carcinoma in situ which includes features of inflammation where neutrophils are present in the epithelium and congestion causes dilatation and engorgement of the blood vessels and the epithelium becomes displaced. ( Lakhani, Dilly, Finlayson 2009).

23 Investigations for Bladder Cancer (1) Cystoscopy Flexible / Rigid - obtain biopsy samples of suspicious lesions. Attempts to include the bladder muscle in the biopsy specimen is important, this allows the pathologist to determine whether the tumour is muscle invasive. An attempt to re- resect the primary tumour should be completed known as TURBT. Steinberg et al (2010). (14 Algorithm) An MRI scan of the pelvis or CT of the Thorax Abdomen Pelvis (CTTAP) can be used to determine the presence of lymphadenopathy or extravesical disease. MRI is superior to CT in the local staging of bladder cancer. Barentz &Witjes (1998). (14 Algorithm).

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25 Investigations for Bladder Cancer (2) Imaging of the upper urinary tract: Traditionally this was always done by means of an intravenous urogram (IVU) but more commonly done these days by contrast CT An ultrasound scan combined with an ordinary abdominal x-ray is a viable alternative to IVU or CT. The advantages of ultrasound are that it does not involve any radiation or contrast medium and that it is non-invasive. Ultrasound is also more sensitive than IVU in the detection of small tumours of the renal parenchyma. Ultrasound is less sensitive than IVU in the detection of small tumours of the drainage system of the kidney, however, the accuracy of ultrasound is dependent on the skill of the person performing the procedure. Ultrasound and IVU should be seen as complementary rather than mutually exclusive. In some patients it may be necessary to perform both tests in order to make an accurate diagnosis. If ultrasound or IVU suggests a mass in the kidney, then a CT scan is usually used as a first line investigation in haematuria. An ultrasound scan or intravenous urogram cannot rule out the presence of a bladder tumour. All patients with haematuria should undergo cystoscopy. ( Algorithm 14).

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27 Types of Bladder Cancer Types of Tumour Because of the complex nature of development of the bladder a variety of tumours occur. Transitional Cell Carcinoma (TCC) 85% Squamous Cell Carcinoma (SCC) 5% Adenocarcinoma 2% Rhabdomyosarcoma and others 1% Causes of Bladder Cancer: There is no single cause but there are several risk factors: Smoking (bea nahthylene) Exposure to certain chemicals i.e. aniline. Exposure to petroleum products e.g. car exhaust, gas cutting equipment. Schistosomiasis (Biharzia) Analgesic abuse (Phenacetin) Chronic infection. (Algorithm 18)

28 Bladder Cancer Sequential course of disease condition More than 70% of all newly diagnosed bladder cancers are non-muscle invasive 50-70% are Ta 20-30% are T1 10% are CIS. Approximately 5% of patients present with metastatic disease, which commonly involves the lymph nodes, lung, liver and bone. Approximately 25% of affected patients have muscle invasive disease at diagnosis. Steinberg et al (2010).

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30 Haemorrhagic Cystitis Undergone pelvic radiation, chemotherapy or both. Matthews et al (1999). According to Chong et al (2005); Corman et al (2003); Levenback et al (1994) and Matthews et al (1999). 10% of patients who undergo pelvic irradiation 70% of patients exposed to high doses of cyclophosphamide or iphosphamide chemotherapy Matthews et al (1999). Upon examination, the patient often demonstrates suprapubic fullness and discomfort or pain to palpation, as well as costovertebral angle tenderness if the bladder obstruction is chronic. Underlying Pathological Process Characterised by inflammation of the bladder associated with haematuria. The symptoms are caused by a microscopic progressive obliterative endarteritis that leads to mucosal ischemia. The ischemic bladder mucosa then ulcerates and bleeding ensues. Neovascular ingrowth to the damaged area, then occurs causing the characteristic vascular blush on cystoscopic evaluation. The new muscles are more fragile and may leak with bladder distension, minor trauma or any mucosal irritation. Submucosal haemorrhage and overt haematuria may then begin precipitously. The histological appearance of haemorrhagic cystitis is more vascular with mucosal ulceration and haemorrhage, inflammation is present and lymphocytes are in abundance. ( Lakhani, Dilly, Finlayson 2009).

31 Diagnostic Modalities Assessed in the same way as for bladder cancer. In Natasha s case a renal ultrasound was initiated to identify any upper tract lesions. McCarville et al (2000) and Worawattanakul et al (1997). (15 Algorithm) Often, cystoscopic clot evaluation is necessary to allow inspection of the urothelium. Even in situations in which clots are initially removed with continuous bladder irrigation, an endoscopic inspection is essential in planning treatment and in preventing future episodes. Chronic inflammation is the most common finding on a bladder biopsy specimen. Basler and Miyamoto (2009). Surgical intervention other than Cystoscopy with cauterization is reserved for cases in which medical management fails. In extreme cases, when all other treatment options have failed, selective or superselective hypogastric branch artery embolization can be considered.

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33 Urinary Tract Infection (1) UTI s may be referred to as cystitis or pyelonephritis Uropathogens are specific bacteria that have been clinically associated with invasion of the urinary tract. Complicated UTI s may be subdivided into four categories; Structural abnormalities, Metabolic or hormonal abnormalities, Impaired host responses and Unusual pathogens for example yeast. (12 Algorithm)

34 Urinary Tract Infections (2) Diagnostic Modalities Further tests such as Glomerular Filtration Rate (GFR), Protien Creatinine Ratio (PCR) or Albumin Creatinine Ratio (ACR) should be carried out if a urological cause has been excluded and a nephrology referral should be considered. Criteria for referral to Nephrology (21- Algorithm) The IVU is the traditional standard for upper tract urothelium imaging; however it is poor for evaluating the renal parenchyma. (Steinberg et al 2010). (16 Algorithm).

35 Urinary Tract Infections-some facts (3) Factors unfavourable to bacterial growth include a low Ph (5.5 or less, a high concentration of Urea and the presence of organic acids derived from a diet that includes fruits and protien. Sexual intercourse contributes to increased risk, as does use of a diaphragm and /or spermicide. The high urine glucose content in patients with diabetes mellitus. Rates of infection are high in postmenopausal women loss of estrogen. The prognosis for most women with cystitis and pyelonephritis is good; about 25% of women with cystitis will experience a recurrence. TB of the Kidney results from hematogenous spread but is relatively rare in developing countries. TB of the kidney does not manifest until 5-15 years after the primary infection. UTI s have been well studied in Sweden and other parts of Europe. As 1 in 5 adult women experience UTI at some point, it is an exceedingly common, clinically apparent, worldwide patient problem.

36 Criteria for Referral to Nephrology 24 hour urine collections for protein are rarely required. An approximation to the 24hour urine protein or albumen secretion is obtained by multiplying the ratio (in mg/mmol) x10. The need for a nephrology referral in this situation depends on factors other than simply the presence of haematuria. Nephrology referral is recommended if there is concurrent: Evidence of declining GFR by > 10ml/min at any stage within the previous 5 years or by > 5ml/min within the last one year; Stage four or five chronic kidney disease, that is a GFR of < 30ml/min; Significant protienuria ACR less than or equal to 30 mg/mmol or PCR of greater than or equal to 50 mg/mmol. Isolated haematuria, that is in the absence of significant protienuria with hypertension in those aged less than 40. Visible haematuria coinciding with intercurrent, usually upper respiratory tract infection. BAUS/RA Guidelines (2008)

37 Conclusion Diagnosis was confirmed as recurrent Ta G1 TCC which requires regular Cystoscopy, possible resection and serial radiological review. External beam radiotherapy has been shown to be inferior to radical Cystectomy for the treatment of bladder cancer. The overall 5 year survival after treatment with external beam radiotherapy is 20-40% compared to 90% 5-year survival after Cystectomy for organ confined disease. In Natasha s case she made an informed decision regarding definitive treatment bladder cancer and choose external beam radiotherapy, it may be that she will require a salvage Cystectomy in her future management. (Steinberg et al 2010). Devising this algorithm has lead to a logical approach to the diagnosis of frequent patient presentations encountered in my area of clinical practice. It has further assisted me to develop a valid approach in differential diagnosis for macroscopic haematuria by indicating in a structured manner, recurrent encountered decisions in the diagnostic reasoning pathway

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