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Hematuria & Stones
Clinical Medicine II
Question | Answer |
---|---|
Definition of hematuria | > 3 RBCs per High Power field in 2-3 properly collected urine over 2-3 weeks (by AUA) |
Evaluation of hematuria indications | >2 RBCs by HPF |
“Clean Catch” Urine sample | spread labia/retract foreskin, swab urethral area, start urination, then bring sterile container into stream (don’t stop flow) 1-2 Tbsp of urine |
What are some false positives for blood w/ urine dipstick | menstrual, myoglobinuria, Hbguria, semen, betadine, bacterial enzymes from vaginal infections, dehydration |
Urine Dipstick checks for | blood/heme, protein, nitrite, pH, glucose, ketones, bilirubin, leukocytes, specific gravity |
3 steps to urinalysis | physical color/appearance, specific gravity, microscopic appearance (RBCs, WBCs, mucus, crystals, bacteria) |
Colors indicate what, dark yellow, Orange, gree, blue, pink/red/cola-colored | Dark: dehydrated, O: foods/meds, bilirubin, Green: foods/meeds, UTI pseudomonas B: F/M, familia hypercalciuria, P/R/C: blood |
Usually NOT found in urine | hgb, nitrates, WBCs, RBCs >2-3, glucose, ketones, protein, bilirubin |
Cath UA indications | kids w/ FOD to young to CC, menstruating-UTI, vaginal discharge, to debilitated, sepsis or severe illness |
Does degree of hematuria correspond to seriousness of underlying cause | no |
Suspicions <40 and >40 cause | <40: renal stones, UTIs, >40: same, + bladder, kidney, prostate cancers |
RBCs + proteinuria means what | glomerular source |
Why does proteins suggest glomerular source | the rents are disrupted and RBCs are damaged: and ↓ of filtration |
Color for glomerular hematuria | often brown or cola-coloared d/t ↑ transit time, RBC casts and damaged RBCs often found |
Causes for glomerular hematuria | glomerulonephritis, IaA nephropathy, thin basement membrane nephropathy, hereditary nephritis, lupus, vasculitis, chronic interstitial nephritis |
Vasculitis cause of glomerular hermaturia think what – wegener’s granulomatosis | |
Hereditary nephritis | alport syndrome |
igA nephropathy | Berger’s Disease |
If blood is urine is nl suggests what aka no dysmorphic casts | extraglomerular hematuria |
Causes of extraglomerular hematuria | infx, nephrolithiasis (kidney), calculus, malignancy, cystic dz, vascular d/o, endometriosis, BPH, urethritis, urethral trauma |
MC cause of hematuria | infections, Renal stones, BPH, cancer |
Glomerular blood | red, smoky brown, no clots, protein could be >500mg/day, dysmorphic RBCs, casts |
Extraglomurlar blood | red, pink, maybe clots, <500mg/day proteins, nl RBC, no RBC casts |
Why would a dipstick be + for blood | hemoglobinuria: hemolysis, and Myoglobinuria: rhabdomyolysis |
Medications that cause false + | rifampin, nitrofurantoin, phenytoin, ibuprofen |
What are some food dyes that may cause pseudohematuria | beets, rhubarb, berries |
Ddx for dysuria, pyuria, fever | UTI, pyelo, prostatitis, urethritis, malignancy |
DDx for urethral discharge | urethrisits, prostitis |
DDx for flank pain | pyelo, stones, neoplasms, ischemia, GN |
DDx for hesitancy, dribbling | BPH |
DDX for gross, painless hematuria | bladder cancer, postinfectious GN |
DDx for fevers, rash arthritis | GN assoc w/ SLE vasculitis |
DDx for pt w/ hematuria and recent ravel | schistosoma, Tb |
DDx for suprapubic tendernesss | UTI |
DDx for CVA tenderness | pyelonephritis |
MC causes of Hematuria | UTI, urolithiasis, BPH, Urologic Malignancy |
What electrolytes should we remember to check | Na, K, Ca, P |
If + urine cultures, or stones what should we do | repeat UA 2-6weeks, Stones: repeat after stone clearance |
Limitations of imaging for IV urogram | poor sensitivity to characterize renal parenchymal masses. IV contrast (same as retrograde pyelogram) |
When does proteinuria become concerning | >500mg/dl |
Gold standard for images | CT urogram (lg radiation, and expensive) later step |
Indications of cystoscopy | lower urinary track suspicion, can do biopsy (urether and bladder) |
If there is a bladder tumor, what else should we do | do upper urinary tract imaging (same cell lines) |
What is urine cytology especially good at | ↑specific/sensitivity for high grade urothelia carcinoma (limited for low grade dz) (can do urine cytology from cystoscopy) |
If no clear cut cause found, what do we do | MUST follow up, usually infx/stones though |
Nephrolithiasis | urinary tract stones: crystalline mineral concentrations (recurrence common) |
Stone composition | calcium, oxalate, Uric acid, phosphate |
Causes of stone development | supersturation, deficiency of stone inhibitors, substrate stone formation, ↓ water vol |
Risks for Calcium oxalate stones | ↓ urine vol, Hyper calcemia, calciruia, oxalurai, hypocitraturia, gouty diathesis (MC w/ 36-70%) |
Risks for Calcium phosphate | ↓urine, UTI, hyperPTH, distal renal tub acidosis |
Mixed oxalate and phosphate risks | all of the above |
Infectio-related causes of stones | called struvite: UTI, urea splitting organisms |
Urea splitting organism | proteus, klebsiella, pseudomonas, staph, |
Uric acid stone RF’s | ↓ urine, pH<6, obesity, hyperuricemia, uricosuria, gout alcohol abuse, gongenetial metabolic erros, nephropathy, gouty arthritis |
Cystine stone RF’s | cystinuria, congenital intestinal tract defect, congenital transport error |
Hx of congenital anatomic defects | medullary sponge kidney, horseshoe kidney, urethropelvic jxn obstruction |
Where is Ca++ absorbed | 90% small intestine, 20-40% in pt’s w/ stones |
Dietary RF’s | drinking <1L of water a day, ↓ vol urine, ↑ animal protein, |
Environmental factors for kidney stones | hot arid climate, excessive fluid loss from sweating, ↓ urine vol |
Signs of kidney stones | Severe pain: tachy, HTN, fever: UTI, pylo |
What are clinical signs of large stones | urinary tract obstruction, |
Reccurent stones, what do we do | Urology, 24 hr collection, check for Ca+, uricosuria, citraturia analyze stones |
What size of stones will uaually pass | <5mm |
What are some medical expulsive therapies | CCBs, alpha-blockers |
What do larger stores require | llithotripsy or surgical management |
What is the preferred tx for most renal stones | Extracorporeal shock wave lithotripsy (ESWL) |
Most common complication of ESWL | pain, hematomas in 5-20% |
When do we use percutaneous nephrolithotomy (PCNL) | stones >2cm near the pelvis, many complications |
Chronic stone management | ^fluid 2.5L a days, ↓Na+, diruetics, reduce pH to below 6.0 for struvite stones |
Chronic management for uric acid stones | allopurinol, high pH, citrate |
Why do we alkalize urine to tx chronic stone management | cysteine stones, K+ citrate to maintain pH 6.5-7 |