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It’s a Bloody Mess!

It’s a Bloody Mess!. Hematuria Wanda C. Hancock, MHSA, PA-C. Objectives. Discover the presenting symptoms for hematuria and the anticipated decision path for its etiology Develop an initial differential diagnosis for hematuria Consider the diagnostic orders for developing the diagnosis

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It’s a Bloody Mess!

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  1. It’s a Bloody Mess! Hematuria Wanda C. Hancock, MHSA, PA-C

  2. Objectives • Discover the presenting symptoms for hematuria and the anticipated decision path for its etiology • Develop an initial differential diagnosis for hematuria • Consider the diagnostic orders for developing the diagnosis • Determine the likely follow up testing.

  3. Hematuria is a sign of malignancy until proven otherwise

  4. Incidence • 43% of microscopic hematuria has no etiology • 5% of microscopic hematuria is cancer • 23% of gross has cancer as an initial finding • 8% has no etiology initially but 18% findings later

  5. Causes • Cancer • BPH • Trauma • Surgery/instrumentation • Medications • Renal Disease • Exercise • Stones • Radiation • Chemotherapy • Fever • Benzenes • UTI • Recent URTI

  6. Risk Factors • Age • Smoking • Trauma • Previous exposure to chemicals

  7. How to Shine…. • Gross or microscopic? • Timing? • Pain? • Clots?

  8. Gross VS Micro • Gross hematuria • Always needs evaluation • Sources • Microscopic • Dip stick has 90% sensitivity • 3-5 RBC HPF • 2 of 3 tests positive

  9. Timing …. • Initiation of the stream • Terminal hematuria • Throughout the micturation

  10. Painful versus painless • Painful • Cystitis • Stones • Painless • Neoplasm

  11. Clots? • Amorphous • Veriform

  12. PeePee on T(4)his • Period, pseudo hematuria • Prostate • Obstruction • Nephritis • Trauma • Tumor • TB • Thrombosis • Hematologic • Infection/Inflammation • Stone

  13. Evaluation • PMH • FMH • PE • Laboratory • Imaging

  14. Past Medical History • Radiation • Surgery • TB • Autoimmune disease • Exercise • Trauma • Recent URTI • LUTS

  15. Family History • HTN • PCKD • Alport Syndrome • Stones • Cancer

  16. Physical Examination • Blood pressure • Pallor • Rashes • Edema • Murmur • Palpable mass • Flank pain • DRE • Pelvic

  17. Laboratory tests • Urine Dip • Microscopic examination • Culture • Cytology • Creatinine, BUN • PT/INR • Urovision • Other • ANA • SCD • TB

  18. Imaging • IVP or CT urogram • Ultrasound • MRI or CT • Retrograde pyelogram • Mag 3 / renal scan • Cystogram

  19. Differential Diagnosis • Pseudohematuria • Drugs, vegatables, dyes • Myoglobin • Menstration • Dysfunctional bleeding • Congenital • Cystic renal disease • Alports disease • Renal tubual disorder

  20. Differential Diagnosis • Anatomic • Strictures • Phimosis • Posterior urethral valves • Diverticulum • UPJ obstruction • Vesicouretric reflux • Vascular malformation • Trauma • Exercise induced • Foreign body/inflammatory

  21. Follow Up • Negative CT, cytology, cystoscopy • Clinic follow up should be scheduled • 6, 12, 24, 36 months • UA, BP, cytology • Retesting • Change of symptoms • Gross hematuria develops

  22. Resources • Campbell-Walsh Urology, 9th edition. Wein, Alan, et al. Saunders/Elsevier, Philadelphia, PA, 2007. • Clinical Manual of Urology, 3rd edition. Hanno, Phillip, Malkowicz, S. Bruce, Wein, Alan. McGraw-Hill, NY, NY, 2007. • Office Urology: The Clinican’s Guide. Kursh, Elroy D., Ulchaker, James C.. Humana Press, Totowa, NJ, 2001. • Pocket Guide to Urology, 3rd edition. Wieder, Jeff A.. Griffith Publishing, Caldwell, ID, 2007. • Smith’s General Urology, 17thedition.Tanngho, Emil A., McAninch, Jack W.. McGraw-Hill/Lange, NY, NY, 2008. • The 5-Minute Urologic Consult, 2nd edition. Gomella, Leonard G. Lippincott Williams & Wilkins, Philadelphia, PA, 2010. • Urology House Officer Series, 4th edition. Macfarlane, Michael T. Lippincott Williams & Wilkins, Philadelphia, PA, 2006.

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