Download Introduction - Valley Urological Associates

H E M AT U R I A
Introduction
The word hematuria is derived from the Greek equivalent <hemat> meaning blood and the
New Latin equivalent <uria> meaning urine; hence hematuria translates into blood in the urine.
Hematuria is one of the most common conditions, that urologists are called upon to investigate
or diagnose and often treat. This pamphlet is designed to help the patient better understand
the nature and possible significance of this condition as well as explain the various tests
and procedures required during this investigation.
The Urinary System
The human urinary system is a complicated grouping
of several important structures (See Figure 1) including
the paired kidneys and ureters as well as the single
urinary bladder and urethra.
The primary function of this system is to rid the
body and blood stream of a number of “poisons”
or toxic materials produced during normal body
functioning.
The cleansing process begins in the kidneys,
which each receive approximately 25 gallons of blood
per day. This blood flows into the kidneys via arteries,
is processed or filtered, and the cleansed blood flow
out of the kidneys via veins. During this filtration
process the body’s poisons, including chemicals such
as urea and uric acid, as well as excess body water
are deposited as urine into a variety of collection
chambers, which ultimately lead to the ureters. The
Figure 1
ureters act simply as conduits and carry the urine into
the urinary reservoir or bladder. The bladder stores
urine until such time as it is convenient and socially
acceptable for the individual to urinate. At this time,
the urine is expelled to the outside through the last
part of the urinary system, the urethra. It is important
to realize that all aspects of the urinary system,
except the urethra, are essentially the same in both
females and males.
In females, the urethra consists of a relatively
uncomplicated, short (1 – 2 inch), straight tube.
In males, the urethra is not only considerably longer
and more tortuous, but it is also surrounded by
the prostate gland, all of which makes it a more
complicated, and hence more disease- prone
structure than its female counterpart.
Hematuria is frequently described as gross or
microscopic. The term gross hematuria implies that
the blood in the urine is actually visible to the naked
eye. Often the patient describes the passage of bright
or dark red or rusty or brownish colored urine,
with or without the simultaneous passage of dark
reddish solid blood clots. This type of hematuria is
understandably very alarming to the patient.
Microscopic hematuria, on the other hand,
describes the condition in which the urine has
a normal yellowish appearance, but nevertheless
blood can be demonstrated when a urine specimen
is examined under the microscope or tested chemically
with a dip-stick. A wide variety of abnormal conditions
anywhere along the course of the urinary system can
result in the presence of blood within the urine. Some of
these conditions such as low grade infections or small
ruptured blood vessels frequently heal themselves and are
of little consequence, while others, such as inflammations
of the kidneys, stones, blockages (obstructions) or
malignancies require specific medical or surgical
treatment and can be life-threatening. It is the job
of the urologist to determine the location and nature
of any such condition as well as to prescribe any
required treatment. The following steps are characteristic
of an evaluation of hematuria.
Medical History: A detailed history of the patient’s
experience with the hematuria (i.e.: gross versus
microscopic bleeding, presence or absence of associated
kidney pain, etc.) as well as any other current or prior
urologic or general medial experiences (i.e.: prior
history of kidney stones or treatment with blood thinners
such as Coumadin, etc.) is obviously important.
Physical Examination: A general medical examination
with emphasis on the urinary system could indicate
a mass (growth) in one of the kidneys or abrasions
or ulcerations on the penis or vagina near the urethral
opening such that blood from these areas could
accidentally mix with the voided urine.
Urinalysis: The patient’s urine would obviously
be examined for blood but also for infection cells
(simple kidney or bladder infections frequently are
associated with hematuria), protein (kidney inflammationsglomerulonephritis usually produce blood and protein
in the urine), and sugar.
Urine Culture: Formal evaluation of urine for infection
usually requires a urine culture, which is a study
designed to determine whether or not bacteria
can be grown from the patient’s urine.
Urine Cytology: Many malignancies of the urinary
system shed cancerous appearing cells into the urine.
Utilizing techniques similar to the female Pap smear,
these cells can be identified.
Blood Tests: Blood tests (BUN and Creatinine) to
evaluate overall kidney functions are often helpful.
Kidney Ultrasound: This study utilizes harmless,
high frequency sound waves to create an image
or picture of the kidneys. A small-lubricated probe
is gently rubbed over the upper abdomen as the picture
is observed on a television screen. Kidney tumors,
stones, and/or blockages can be easily noted.
Intravenous Pyelogram: The Intravenous Pyelogram
or IVP represents another method of viewing the
kidneys and ureters. A liquid “dye” or contrast
material is injected into the patient’s blood stream
and a few minutes later, as the material is excreted
into the urinary system, a series of X-rays clearly
demonstrate these important structures. An IVP
can uncover a wide variety of causes of hematuria
including stones, tumors, and blockages.
Computerized Tomography: At times, preliminary
studies such as a kidney ultrasound or an IVP will
suggest, but not be specific enough, to diagnose an
abnormality. Under these circumstances, a computerized
tomogram or CAT scan may be performed. Like an IVP,
contract material is injected and then a series of cross
sectional X-rays are performed yielding detailed
images of the patient’s internal anatomy.
Cystoscopy: The primary aspects of the urinary
system visualized by X-rays such as sonograms,
IVP’s and/or CAT scans are the kidneys and ureters.
On the other hand, the urinary bladder and urethra
are optimally examined by direct visualization with
the cystoscope. This small, lubricated instrument is
gently passed down the anesthetized urethra into the
bladder. Common abnormalities such as scarring or
strictures of the urethra, prostatic enlargement (in
the male), bladder tumors, or bladder stones can be
easily located. Contrary to popular misconception,
cystoscopy can be safely and comfortably performed
as an office procedure and rarely requires the risks
of general anesthesia.
Retrograde Pyelogram: On occasion, the ureters or
the interior of the kidneys are not well delineated on
standard X-rays such as sonograms or IVP’s. Under
these circumstances, the cystoscopic examination of
the bladder can be extended to include a retrograde
pyelogram. In the study, the X-ray “dye” or contrast
material is directly injected into the ureters and hence
into the kidneys as both structures are viewed on a
television-type screen. The most significant causes of
hematuria diagnosed or excluded during this study
include ureteral or kidney stones, tumors, or blockages.
Most patients with hematuria do not require all
of these tests. The patient’s urologist will select those
tests most appropriate for the given situation. Remember,
the overall aim of the evaluation is to very thoroughly
evaluate the urinary system in the safest, most efficient,
and least costly manner.
What Could Be The Cause Of The Hematuria
And What Treatment Would Be Required?
Depending upon the patient’s type of hematuria,
his or her age and sex, and the presence of associated
symptoms and/or physical findings, a number of possible
causes for hematuria must be considered. In approximate
order of increasing frequency, these would include
the following:
Inflammations (not infections) of the kidneys
Tumors of the Ureters
Tumors of the Kidneys
Kidney Stones
Tumors of the Urinary Bladder
Blockages of the Ureters
Bladder Stones
Prostatic Enlargement
Urinary Infections
Inflammations of the Bladder
Necessary treatment would obviously depend upon
the type of condition diagnosed. At times, simple patient
observation (i.e.: with prostatic enlargement) might
be appropriate, while in other circumstances
(i.e.: with urinary infection) medications such as
antibiotics might be prescribed. Tumors (malignancies)
and/or blockages frequently require surgery.
not require treatment and almost never leads to
any long-term health problems.
What If The Cause Cannot Be Determined?
It is quite common, especially with microscopic
hematuria, that the tests will all prove to be normal
and no specific cause for the hematuria can be
detected. This situation is often quite unsettling for the
patient. In reality, however, not finding a tumor, stone,
or blockage is actually “good news”. In these cases,
the urinary bleeding is often referred to as “benign
hematuria,” meaning that the hematuria is not being
produced by a significant abnormality. It is assumed
in benign hematuria that there is possibly a microscopic
“leak” in the kidney filtration process, resulting
in small amounts of blood seeping into the urine.
This situation is of no consequence since it does
What About the Future?
Assuming the evaluation has uncovered no
major problems, most urologists would simply
observe the patient’s course. A repeat medical history,
physical examination, and most likely, another urinalyses
would be appropriate in 4 to 6 months. Repeating
any of the other studies would probably not be necessary.
Benign, microscopic hematuria is very frequently
persistent and long lasting. Thus, patients should be
cautioned not to become alarmed if future urinalysis
again demonstrates blood. On the other hand, should
a patient again experience gross (visible) urinary
bleeding, the urologist should be immediately notified.