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
Haematuria presence
of Red Blood Cells in
the urine.
Distinctions
Macroscopic
Microscopic (Cameron 1996)
Painful
Painless

Nephrological Initial
Urological Terminal
Differential Diagnosis Total
 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
http://www.ncchta.org/execsumm/summ1018.htm )
 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 Urethra and Penis

BPH, Trauma
Adenocarcinoma 90% Urethral and penile tumours -
Prostatitis !%
Urethritis
 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
 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.
 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)
 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)
 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)
 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 Natashas 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).
 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. Natashas haemoglobin was 12g/dl (Steinberg et al 2010)
(7 - Algorithm) FBC and U & Es 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.
Urinalysis
 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 anti-

platelet 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)
 CLINITEK

Step 1 Step 2 Step 3 Step 4

Completely While removing the strip, After the appropriate For enhanced
immerse all run the edge against the time, compare test convenience and
reagent areas into rim of the urine container areas closely with the standardisation, use
fresh, well-mixed, to remove excess urine. corresponding colour a CLINITEK
uncentrifuged Hold the strip in a chart on the bottle label analyser to read the
urine. Dip briefly horizontal position to or bench reader at the reagent strip and
and remove prevent possible mixing of time specified. Hold print the results
immediately to chemicals from adjacent strip close to colour
avoid dissolving reagent areas or soiling of blocks and match
out reagents. hands with urine. carefully. Always record
the results.
Urothialisis (1)
 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
 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 ureters 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).
 Bladder Cancer
Bladder cancer is the 8th 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 50-59 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).
 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).
 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).
 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)
 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).
 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).
 Diagnostic Modalities
Assessed in the same way as for bladder cancer.
In Natashas 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.
 Urinary Tract Infection (1)
UTIs may be referred to as cystitis or pyelonephritis
Uropathogens are specific bacteria that have been clinically
associated with invasion of the urinary tract.
Complicated UTIs may be subdivided into four categories;
Structural abnormalities,
Metabolic or hormonal abnormalities,
Impaired host responses and
Unusual pathogens for example yeast. (12 Algorithm)
 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).
 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.

UTIs 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.
 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)
 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 Natashas 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