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Sunday, 25 March 2012

Management of Patients with Haematuria Complaints


Management of Patients with Haematuria Complaints

Hematuri is a medical term that describes the discovery of blood in the urine. Hematuria is an important phenomenon in the field of urology that reflect a variety of renal diseases and channel. Hematuri always causes sufferers seek medical help. A person who suffers hematuri should be examined more to see to it that causes localized bleeding and that can be known and determined the severity and persistence. When we review the possible causes of each patient with hematuri hematuri should we consider a serious condition.
Hematuri clinically divided into two groups, namely hematuri macroscopic (= makrohematuri) and hematuri microscopic (= mikrohematuri). Hematuri macroscopic urine is mixed with blood and can be seen with the naked eye. Makrohematuri already can occur if there is 1 cc of blood in 1 liter of urine. The color of urine from gross hematuria originating from the glomerulus brown, tea or coca-cola, while gross hematuria originating from the lower urinary tract (bladder or urethra) colored younger.
Mikrohematuri hematuri which is in plain view can not be seen as the red-colored urine, but on microscopic examination found more than 2 red blood cells per field of view. If the enlargement of 500 times in urine sediment was found more than ten erythrocyt it will give a positive benzidine test. Presence of hematuria should be confirmed by urine sediment examination in the microscope, because many causes other than blood clots that can cause red or brown urine and give a false positive dipstick test.
Isolated microhematuria, with no history or abnormalities on routine urine examination. Urinalysis should be repeated 2 or 3 times in recent months (without preceded by physical exercise) before the start of the next inspection. When microscopic hematuria menetao, a thorough anamnesis should dibut about drug use, family history of hematuria, deafness, kidney failure, urinary tract stones, a history of sickle cell disease or trait.
Macroscopic hematuria that continues over time can be life threatening because it may cause diseases such as: the formation of blood clots that can block the flow of urine, resulting in hypovolemic shock eksanguinasi / anemia and cause urosepsis.

Estimates of Origin hematuri
The blood may come from different parts of kidneys, the glomeruli, tubules and interstisium or from the urinary tract, bladder and urethra. Red blood cells regardless of the glomerular capillaries through gaps in the capillary walls which can not be seen even with an electron microscope examination. Proteinuria, erythrocytes and erythrocyte piston which experienced deformity usually accompanies hematuria in urine from glomerular damage. Renal papillae can be damaged by microthrombi and / or anoxia in patients with hemoglobinopathy or toxin. Patients with renal parenchymal abnormalities may indicate the presence of microscopic or macroscopic hematuria during a systemic infection, or after moderate physical activity. It was as a result of renal hemodynamic response to physical activity or fever. It is important to distinguish between the cause of glomerular hematuria and non-glomerular in order to limit the possibility of diagnosis and direct a more focused examination.




With the examination of three glasses of origin can be roughly estimated from hematuri.
Ways: the urine during micturition is separated into portions I, II and III. If blood is found in the portion of 1 is most likely derived from the urethra, if found in portions 1 and II bleeding from the urinary vesicles. If found in the third portion of blood likely originated from the kidney, bleeding from the kidneys often lead to discovery of the cylinder erithrocyt.

Cause hematuri
Hematuri can be caused by various abnormalities of the kidney, ureter, vesicles, prostate stones and urethra, glans penis + praeputium. Simply hematuri causes can be divided into:
A. Hematuri those from the glans penis praeputium, prostatic urethra and vesicles (lower urinary tract). Hematuri originating from this region is approximately 90% of all hematuri. Hematuri in this area can be caused by:
• balano posthitis
• urethritis
• cystin (especially hemorrhagi)
• prostatitis
• benign prostate enlargement, prostate carcinoma
• vesica urinary tumors and stones
• trauma.
2. Hematuri derived from the ureter. Usually occurs only on one side of the ureter is the most frequent cause of stone sometimes (very rarely) can also be caused by tumors or trauma.
3. Hematuri from pyelum most often caused by inflammation of stones, tumors, abnormal blood vessels in the fornix (rarely) or trauma.
4. Hematuri derived from a typical kidney-cylinder found in the sediment erythrocytes. This can be the cause hematuri by:
• Trauma
• Tumor like Grawitz in children and Wilms tumor. At 60% tumor Grawitz provide hematuri symptoms in addition to pain and palpable tumor. Haemangioma can also bleeding.
• Congenital abnormalities:
o Polycystic kidney gives hematuri in 28-40% of cases.
o solitary renal cysts can also provide hematuri.
o Hydronephrosis may occasionally cause hematuri.
5. Hematuri parenchym caused by kidney disease:
• Glomerulonephritis akuta usually a week later followed by mikrohematuri makrohematuri.
• chronic glomerulonephritis usually mikrohematuri.
• acute pyelonephritis: a makrohematuri Usually, if there is the possibility of necrosis papil makrohematuri remember.
• chronic pyelonephritis: Usually occurs mikrohematuri with occasional sudden makrohematuri.
• Acute interstitial nephritis: Usually found mikrohematuri.
6. Hematuri caused by metabolic disorders or other diseases are also on the kidney such as the
• Amyloidosis
• Kummelstiel - Wilson
• renal tuberculosis (15% of cases)
• Henoch Schonlein Purpura
• thrombocytopenia purpura
• LE is on kidney
• bakteriel sub acute endocarditis.
7. Hematuri caused by impaired renal vascularization
• Embolism renal artery or its branches
• renal vein thrombose
• Hypertension
• Orthostasis, after heavy physical work, in a state of shock or decompensasio Cordis.
8. Hematuri caused by the clotting or bleeding disorders: hemophilia, thrombocytopeni, thrombopati, anticoagulansia excessive dose, after treatment with Butazolidin.
9. Hematuri essential (idiopathic) that can not be found hematuri which is why despite being sought by means of the existing diagnostics.



Figure 1. Possible Origin Hematuria

Management of Patients with Haematuria
Given hematuri is an important and serious symptoms and can be caused by abnormalities of the kidneys to praeputium, then in each patient with hematuri be examined intensively and systematically.
Must be assured in advance, did a patient suffering from hematuria, or bleeding pseudohematuria per-urethra. Pseudo or false hematuria the urine is red or brown are not caused by red blood cells. This situation can be caused by hemoglobinuria, mioglobinuria, increased uric acid concentrations, after every meal / drink material containing pigment of plants that are red, or after consuming some specific drugs, among others: fenotiazine, piridium, porphyrins, rifampicin and fenoftalein. Bleeding per urethra is kelaurnya blood from the external urethra meatus without going through the process of micturition, it is common in trauma or tumor urethra.




Depending on the facilities available the systematic examination of patients with hematuria can be arranged systematically commonly usual hematuri is a patient should be examined as follows:
A. anamnesis
In searching for causes of hematuria have unearthed data that occurs during episodes of hematuria, among others:
• How does the color of urine comes out? Asked about the nature of the macro or micro hematuri whether or clotted (followed by a discharge of blood clots)

Table 3. Urine color and Causes



In what part during micturition urine red?
Characteristics of a hematuria can be used as a guideline to estimate the location of the primary disease, ie whether the red color occurs at the beginning of micturition, all the process of micturition, or at the end of micturition.

Table 4. Hematuria portion at the time of micturition





The quality of the color of urine can also help determine the cause of hematuria. New blood coming from the bladder, prostate, and urethra red fresh blood while old or glomerulus derived from brown colored with a shape like a worm (vermiform)
• What is the first time or frequent, intermittent.
• Is accompanied by pain.
Pain that accompanies the hematuria can come from pain in the upper urinary tract colic or a symptom of irritation of the lower urinary seluran of dysuria or stranguria.
• Is accompanied by signs of infection such as heat, shivering. If accompanied by fever, letargis, abdominal pain, swollen or specific symptoms such as dysuria urinary tract, frequent urination, it is most likely a urinary tract infection.
• Have had bladder stones.
• Are there any trauma.
• Do use drugs to excess, and in the long term.
• The decline of nutrition.
• Have a sore throat pain swallowing or 10-14 days (or a skin infection 4-6 weeks prior to the occurrence of hematuria, it is likely that post-streptococcal glomerulonephritis is.
• If there is a history of skin rash, especially if there is butterfly rash on the face, munkin is a systemic lupus erythematosus, or if the rash then chances are shaped purpura Henoch Schonlein purpura.
• History of past diseases also need to be tracked, such as a history of renal trauma, disorders of hemostasis physiology, or hematuria in the family. A history of deafness in a family with renal failure, especially in the families of men are very likely an Alport syndrome. Similarly, the existence of autosomal dominant polycystic kidney disease in the family.
• It should also be asked about risk factors for hematuria that age> 40 years, male gender, smoking habit, history of exposure to chemicals (cyclophosphamide, benzene, aromatic amines), history of radiation exposure in the pelvis, a history of irritating symptoms (urgency, frequency, dysuria) and a history of previous urological disease or treatment.
2. Physical examination
• Look for the presence of hypertension may be a manifestation of a kidney disease.
• hypovolemic shock and anemia may be caused by a lot of blood coming out.
• The discovery of signs of bleeding elsewhere may indicate a disorder of blood clotting system is systemic.
• Fingering the kidney enlargement by bimanual palpation. Please note due to an enlarged kidney tumor, renal obstruction and infection.
Fingering suprasymphisis area. Suprasimfisis mass might be due to retention of blood clots in the bladder.
• Inspection of the genitalia externa, especially in the area and praeputium meatus.
• Examination of rectal toucher primarily to evaluate the prostate and bimanual palpation in the prostate and vesicles.
3. laboratory tests
• complete urine examination, culture + resistance test, urine examination cytologi acid-fast bacilli. Examination may lead us pafa urinalysis hematuria caused by factors or non glomeruler glomeruler. On examination of the highly alkaline pH of urine indicates the breaking of urea in the organism of infection in the urinary tract, whereas the highly acidic urine pH may be related to uric acid. Urine cytology is required to seek the possibility of malignant urothelial cells.
Hemturia microscopic enforced meaningful if at least 3 times in a urinalysis examination within a period of 2-3 weeks showed that there are 5 or more red blood cells per field of view. Dipstick test is a sensitive screening tests to ensure the presence of blood in the urine. Dispstick consists of a piece of paper filled with hydroperoxide and tetramethylbenzidine. Peroxidase-like activity of hemoglobin catalyzes a reaction that causes the blue color of green. The test can detect free hmeglobin at least 150 g / l, equivalent to 5-20 intact red blood cells per mm3 of urine. Positive palsy occurs when urine is contaminated with bleach cleanser soap reservoir urine tube. False negatives occur when the urine has a high specific gravity or sakorbat acid in high levels.
Urine samples that test positive dipsticknya should always be confirmed by microscopic examination to furnish information on the number of erythrocytes, the presence of other cells, piston, crystals and bacteria.



Blood Hb, Leuco, Differential, erythrocyte sedimentation rate, clotting mechanism and test the bleeding.
• Examination of "tumor markers".
• Examination of kidney function and liver function.
4. Radiological examination
Plain and photo checks pyelografi intravenously. With an indication of firm:
• pyelografi retrograde examination (and the endoscope). PIV is a routine that is recommended in every case hemturia. This examination may reveal the presence of urinary tract stones, congenital abnormalities of the urinary tract, urotelium tumors, urinary tract trauma, as well as some urinary tract infections. Blood clot or tumor uretelium often encountered as the filling defect image can be seen in pelvikaliseal system, ureter and bladder.
• examination of renal arteriography
• cystografi
• ultrasonography. Ultrasound examination is useful to see a solid mass or kistus, a non-opaque stones, blood clots in buli-buli/pielum, and to detect metastatic tumor in the liver.

5. Endoscopic examination
Useful for: notice any abnormalities in the urethra, prostate, vesicles and determine the bleeding of the upper urinary tract (upper urinary tract) and from which side; when indicated may well be done to make pyelografi sondage retrograde ureter. At the time of endoscopy patient should be working on common narcotics that are not in pain and if the endoscopic examination found abnormalities such as tumors or stones can be simultaneously performed biopsy or lithotripsy.
6. A renal biopsy
If there is a strong indication that shows hematuri parenchym derived from renal biopsy should be held to confirm the abnormality in anatomic pathology. By conducting the above examination procedure systematically expected to know the cause and localization of hematuri so that rational treatment can be given. When the aforesaid examination found no abnormalities remains then the patient is included in the idiopathic group.

Management
If there is a blood clot in the bladder causing urinary retention, catheterization and attempted refraction jar using physiological saline, but if action is not successful, the patient is immediately referred for a blood clot evacuation transurethra and simultaneously stop the bleeding source. If there eksanguinasi that causes anemia, blood transfusion should difikirkan. Similarly, if an infection should be given antibiotics.
After hematuria can ditanggulangim next action is to find the cause and then solve the problem of primary cause of hematuria.

Figure 3. Algorithm evaluation of patients with gross hematuria


Figure 4. The algorithm of patients with mikrohematuria.







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