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Probability diagnosis

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Infection:

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  • cystitis (both sexes)/urethrotrigonitis (female)

  • urethritis (male)

  • prostatitis (male)

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Calculi-kidney, ureteric, bladder

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Bladder tumour

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Serious disorders not to be missed

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Cardiovascular:

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  • kidney infarction

  • kidney vein thrombosis

  • prostatic varices

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Neoplasia/cancer:

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  • kidney tumour

  • urothelial: bladder, kidney, pelvis, ureter

  • prostate cancer

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Infection:

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  • infective endocarditis

  • kidney tuberculosis

  • acute glomerulonephritis

  • blackwater fever (falciparum malaria)

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IgA nephropathy

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Kidney papillary necrosis

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Other kidney disease

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Pitfalls (often missed)

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Urethral prolapse/caruncle

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Pseudohaematuria (e.g. beetroot, porphyria)

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Benign prostatic hyperplasia

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Trauma: blunt or penetrating

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Foreign bodies

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Bleeding disorders

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Haemorrhagic cystitis

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Exercise (esp. long distance running)

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Radiation cystitis

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Menstrual contamination

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Rarities:

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  • hydronephrosis

  • Henoch–Schönlein purpura

  • schistosomiasis (bilharzia)

  • polycystic kidneys

  • kidney cysts

  • endometriosis (bladder)

  • systemic vasculitides

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Masquerades checklist

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Drugs (cytotoxics, anticoagulants) UTI

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Is the patient trying to tell me something?

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Consider artefactual haematuria.

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Key history

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Is it really haematuria? Red discolouration can be due to haemolysis or red food dye. The history should include nature of haematuria, associations such as pain, sexually transmitted infections, dysuria and frequency. Drug history, athletic history, urological history, sexual history, recent trauma history, travel history.

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Key examination

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  • General examination and vital signs, especially BP

  • Cardiovascular examination to exclude possible kidney embolisation

  • Abdomen examination especially for a palpable enlarged kidney or spleen

  • Suprapubic examination for bladder tenderness or enlargement

  • Consider rectal examination in men and vaginal examination in women

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Key investigations

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  • Urine analysis

  • Urine MC

  • Urine cytology

  • FBE/ESR

  • Appropriate radiology (e.g. intravenous urogram, intravenous pyelogram, ultrasound.

  • Direct imaging (e.g. cystoscopy)

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Diagnostic tips

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  • Macroscopic haematuria is always abnormal except in menstruating women.

  • Common sources of macroscopic haematuria are the bladder, urethra, prostate and kidney.

  • Joggers and athletes engaged in very vigorous exercise can develop transient microscopic haematuria.

  • Common urological cancers that cause haematuria are the bladder (70%), kidney (17%), kidney pelvis or ureter (7%) and prostate (5%).

  • The key radiological investigation is the intravenous urogram (pyelogram).

  • Sometimes blood in the urine can come from the rectum or vagina.

  • Painless frank haematuria is an ominous sign.

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