H(a)ematuria. FX Keeley Consultant Urologist Bristol Urological Institute

Transcription

1 H(a)ematuria FX Keeley Consultant Urologist Bristol Urological Institute

2 From Philadelphia

3

4 to Bristol, England

5 Southmead Hospital, 1916

6 Southmead Hospital, 2013

7 Southmead Hospital, 2014

8 H(a)ematuria

9 Blood in Pee Patient with visible hematuria Refer to hematuria service Patient has either US or CT and cystoscopy Any questions?

10 Case #1 77 y.o. man asymptomatic Quit smoking 10 years ago On warfarin for AF One episode of visible hematuria several months ago Dipstick negative Refer?

11 Case #2 35 y.o. woman with several episodes of severe cystitis in a row Non-smoker Normal BP, egfr Visible hematuria Refer?

12 Case #3 Asymptomatic 58 y.o. male Non-smoker Normal BP, egfr 2 positive dipstick tests, 1 negative Refer?

13 Case #4 37 y.o. woman Visible hematuria after running No risk factors Dipstick negative Refer?

14 69 y.o. woman Case #5 Recurrent episodes of cystitis Multiple visits to surgery and out of hours Antibiotics occasionally help Non-visible hematuria (3+), nitrite negative, leukocyte positive Refer?

15 H(a)ematuria Visible a.k.a. macroscopic, frank, gross versus non-visible (NVH) a.k.a. microscopic, dipstick Associated symptoms Renal v urological Demographics

16 What do the Guidelines Say?

17 Haematuria: Guidance Urine testing for haematuria should only be performed for identifiable clinical reasons; there is currently no evidence to support opportunistic screening of the general population. Joint Consensus Statement of RA and BAUS, 2008

18 Dipstick v Microscopy Urine dipstick of a fresh voided urine sample, containing no preservative, is considered a sensitive means of detecting the presence of haematuria. Community based urine samples sent for microscopy have a significant false negative rate; the procedure is more labour intensive, and adds little to establishing the diagnosis of haematuria. Routine microscopy for confirmation of dipstick haematuria is not necessary. Joint Consensus Statement of RA and BAUS, 2008

19 Trace v 1+ Trace = negative 1+ = positive Joint Consensus Statement of RA and BAUS, 2008

20 Significant Haematuria Visible Symptomatic NVH Persistent asymptomatic NVH 2 out of 3 Exclude transient causes:» UTI» Exercise induced» Menstruation Joint Consensus Statement of RA and BAUS, 2008

21 Visible? Incidence of serious pathology: NVH: 0.2 to 9% Visible: 11 to 20%

22 Signs and Symptoms Pain Dysuria, frequency, urgency Hypertension, CKD, proteinuria

23 Renal v Urological Hypertension Proteinuria Renal function Spot ACR or PCR

24 Demographics Age Sex Smoking Occupation

25 Causes Bladder cancer Prostate cancer Kidney cancer BPH UTI Stones Nephritis Trauma Tb Prostatitis Urethritis Papillary necrosis Upper tract TCC Penile cancer Interstitial cystitis Pyelonephritis Retroperitoneal fibrosis Cystitis systica

26 NICE Guidance 2015 Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are: aged 45 and over and have: unexplained visible haematuria without urinary tract infection or visible haematuria that persists or recurs after successful treatment of urinary tract infection, or aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test. Consider non-urgent referral for bladder cancer in people aged 60 and over with recurrent or persistent unexplained urinary tract infection (new NICE recommendation for 2015).

27 Case #1 77 y.o. man asymptomatic Quit smoking 10 years ago On warfarin for AF One episode of visible hematuria several months ago Dipstick negative Refer?

28 Case #2 35 y.o. woman with several episodes of severe cystitis in a row Non-smoker Normal BP, egfr Visible hematuria Refer?

29 Case #3 Asymptomatic 58 y.o. male Non-smoker Normal BP, egfr 2 positive dipstick tests, 1 negative Refer?

30 Case #4 37 y.o. woman Visible hematuria after running No risk factors Refer?

31 69 y.o. woman Case #5 Recurrent episodes of cystitis Multiple visits to surgery and out of hours Antibiotics occasionally help Non-visible hematuria (3+), nitrite negative, leukocyte positive Refer?

32 Take Home Messages Haematuria guidance has changed Strict rules on asymptomatic microscopic haematuria referral Think before you tick a box Thank you for your attention