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MICROHEMATURIA AND URINARY TRACT INFECTIONS

ANEESA HUSAIN, PA-C

USMD CANCER CENTER ARLINGTON - UROLOGY

I HAVE NO FINANCIAL DISCLOSURES THAT WOULD BE A POTENTIAL CONFLICT OF INTEREST WITH

THIS PRESENTATION.

MICROHEMATURIA

TOPICS OF DISCUSSION

• DEFINITION

• HISTORY

• PHYSICAL EXAM

• DIFFERENTIAL DIAGNOSES

• WORK UP

• TREATMENT

• WHEN TO REFER?

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MICROHEMATURIA

DEFINED AS..

• ≥3 RBCs per HPF (HIGH POWER FIELD) ON URINE MICROSCOPY

• SHOULD NOT BASE SOLELY ON ONE DIPSTICK READING

• CAN CORRELATE TO DIPSTICK URINE ANALYSIS

• TRACE, SMALL, MODERATE, LARGE

https://www.auanet.org/guidelines/asymptomatic-microhematuria-(2012-reviewed-and-validity-confirmed-2016)

MICROHEMATURIA

TOP DIFFERENTIAL DIAGNOSES

• UTI/PROSTATITIS

• KIDNEY STONES

• URINARY TRACT OBSTRUCTION

• URINARY TRACT MALIGNANCY

• NEPHROLOGIC SOURCES

MICROHEMATURIA

HISTORY

• NEW DIAGNOSIS OF MICROHEMATURIA?

• PRIOR HISTORY OF GROSS OR MICROHEMATURIA?

• PRIOR WORK UP

• COMORBIDITIES

• PELVIC RADIATION

• SURGICAL HISTORY

• FOR WOMEN, ASK ABOUT MENSES AND/OR MENOPAUSE

• ANTICOAGULATION OR BLOOD THINNERS

• SYMPTOMS

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MICROHEMATURIA

HISTORY - SYMPTOMS

• DYSURIA

• FREQUENCY

• URGENCY

• DIFFICULTY VOIDING

• INCONTINENCE – PAD USAGE

• ABDOMINAL OR BACK PAIN

• PERINEAL PAIN

MICROHEMATURIA

PHYSICAL EXAM

• ABDOMINAL EXAM

• CVA/FLANK TENDERNESS

• GU EXAM

• MALE – CONSIDER MEATAL STENOSIS, BALANITIS, TESTICULAR PAIN, PROSTATITIS, PROSTATE ENLARGEMENT

• FEMALE – CONSIDER VAGINAL BLEEDING, YEAST INFECTION, ATROPHIC VAGINITIS

MICROHEMATURIA

DIFFERENTIAL DIAGNOSES

• UTI/PROSTATITIS

• KIDNEY STONES

• URINARY TRACT OBSTRUCTION

• URETERAL STONES

• UPJ OBSTRUCTION, HYDRONEPHROSIS

• URETERAL STRICTURE

• BPH

• URETHRAL STRICTURE

• URINARY TRACT MALIGNANCY

• RENAL TUMORS

• BLADDER TUMORS

• URETERAL TUMORS

• RADIATION CYSTITIS

• POST-OP SURGICAL CHANGES: PROSTATE REGROWTH,

CRYOABLATION, MESH/SLING EROSION

• BALANITIS, VAGINITIS, VAGINAL BLEEDING

• NEPHROLOGICAL SOURCES

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http://humananatomylesson.com/anatomy-of-urinary-system/

MICROHEMATURIA

WORK UP

• URINE MICROSCOPY

• URINE SPECIMEN SHOULD BE MID-STREAM VOID OR CATHETERIZED SAMPLE

• URINE CULTURE

• URINE CYTOLOGY

• CT-IVP

• CYSTOSCOPY (AUA RECOMMENDS FOR PATIENTS ≥ 35 OR WITH RISK FACTORS FOR URINARY

TRACT MALIGNANCY)

https://www.auanet.org/guidelines/asymptomatic-microhematuria-(2012-reviewed-and-validity-confirmed-2016)

MICROHEMATURIA URINE SEDIMENT MICROSCOPY

https://www.researchgate.net/profile/Bensson_Samuel/publication/273897399/figure/tbl4/A

S:391968115970051@1470463889150/Table-4-Urinalysis-With-Urine-CS-Reflex.png

https://www.studyblue.com/notes/note/n/urine-casts-cells/deck/16597911

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MICROHEMATURIA URINE CULTURE

http://www.lbah.com/word/bladder-stones/http://www.sciencephoto.com/media/855408/view

MICROHEMATURIACT-IVP

KIDNEY/URETERAL STONES

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-

pathways/gastrointestinal/acute-abdomen/acute-flank-loin-pain-renal-colic

MICROHEMATURIACT-IVP

http://radiopaedia.org/images/1228468

UPJ OBSTRUCTION AND HYDRONEPHROSIS

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MICROHEMATURIACT-IVP

http://uronotes2012.blogspot.com/2012/04/neoplastic-renal-

masses-benign-adenoma.html

RENAL MASS INVADING COLLECTING SYSTEM

MICROHEMATURIA URINE CYTOLOGY

• SCREENS URINE FOR ATYPICAL OR MALIGNANT CELLS

• CANNOT DIAGNOSE CANCER SOLELY BASED ON CYTOLOGY

• RELATED TESTS

• NMP-22

• FISH

• BLADDER CX

• IF CYTOLOGY TESTS ARE POSITIVE OR ABNORMAL, CYSTOSCOPY IS RECOMMENDED

http://www.urologyhealth.org/urologic-conditions/urine-cystology?article=85

http://medical.olympusamerica.com/products/flexible-cysto-nephroscope/cyf-5

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http://dronuma.com.au/cystoscopy/ https://openi.nlm.nih.gov/detailedresult.php?img

=PMC3725437_jmedlife-06-140-g002&req=4http://www.webpathology.com/image.asp?

case=51&n=26

http://stgeorgeurology.com.au/optical-

urethrotomy

http://www.virtantiq.com/Urinary+Blad

der+Stone+Removalhttp://www.canjurol.com/article.php?ID=2357

NORMAL BLADDER TUMOR CYSTITIS

URETHRAL STRICTURE BLADDER STONE BPH – PROSTATE ENLARGEMENT

CYSTOSCOPIC FINDINGS

MICROHEMATURIA

POST-OP SURGICAL CHANGES THAT CAN ALSO BE NOTED ON CYSTOSCOPY:

• PROSTATE REGROWTH

• PROSTATE CRYOABLATION

• MESH/SLING EROSION

MICROHEMATURIA

TREATMENT SHOULD BE BASED ON TEST RESULTS

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MICROHEMATURIA

http://www.lbah.com/word/bladder-stones/

Test: Positive Urine Culture

Diagnosis: Urinary Tract

Infection

Treatment: Antibiotic based

on culture sensitivities

MICROHEMATURIA

DIAGNOSIS: PROSTATITIS

SYMPTOMS: PERINEAL PAIN, DYSURIA, URETHRAL PAIN, FREQUENCY, URGENCY, WEAK STREAM,

HEMATOSPERMIA, PAINFUL EJACULATION

TESTS: NO SPECIFIC ROUTINE TEST; CULTURE MAY BE POSITIVE OR NEGATIVE ; POSITIVE SEMEN

CULTURE

TREATMENT: ANTIBIOTICS, NSAIDS, ALPHA BLOCKERS, WARM SITZ BATHS, AVOIDANCE OF

DIETARY IRRITANTS

MICROHEMATURIA

http://www.imagingpathways.health.wa.gov.au/index.php/imaging-

pathways/gastrointestinal/acute-abdomen/acute-flank-loin-pain-renal-colic

Test: CT scan

Diagnosis: Obstructing UPJ

stone

Treatment: Oral medication +

Hydration, Shockwave

Lithotripsy (ESWL), or

Ureteroscopic Laser Lithotripsy *refer to urology

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MICROHEMATURIA

http://radiopaedia.org/images/1228468

Test: CT scan

Diagnosis: UPJ Obstruction and

Hydronephrosis

Treatment: possible options

based on further work up

include ureteral dilation or

pyeloplasty*refer to urology

MICROHEMATURIA

http://uronotes2012.blogspot.com/2012/04/neoplastic-renal-

masses-benign-adenoma.html

Test: CT scan

Diagnosis: Renal Mass

Invading collecting system

Treatment: Radical

Nephrectomy*refer to urology

http://dronuma.com.au/cystoscopy/ https://openi.nlm.nih.gov/detailedresult.php?img

=PMC3725437_jmedlife-06-140-g002&req=4http://www.webpathology.com/image.asp?

case=51&n=26

NORMAL BLADDER TUMOR CYSTITIS

CYSTOSCOPIC FINDINGS - Treatment

TURBT – TRANSURETHRAL

RESECTION of BLADDER

TUMOR

MONITOR VS. TREAT

DEPENDING ON

OTHER TESTS

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http://stgeorgeurology.com.au/optical-

urethrotomy

http://www.virtantiq.com/Urinary+Blad

der+Stone+Removal

http://www.canjurol.com/article.php?ID=2357URETHRAL STRICTURE BLADDER STONE BPH – PROSTATE ENLARGEMENT

CYSTOSCOPIC FINDINGS - Treatment

DILATION vs. VIU (Visual Internal

Urethrotomy) vs.

URETHROPLASTY

SURGICAL

TREATMENT (CYSTOLITHOLAPAXY)

MEDICAL vs. SURGICAL

THERAPY (such as TURP)

MICROHEMATURIA

TREATMENT CONTINUED…

• BALANITIS: LOTRISONE OR SIMILAR, CONSIDER CIRCUMCISION

• ATROPHIC VAGINITIS: VAGINAL ESTROGEN (IF NO RISK FACTORS)

• ABNORMAL VAGINAL BLEEDING: REFER TO GYNECOLOGY

MICROHEMATURIA

NEPHROLOGIC SOURCES

Refer to nephrology …

• If urological work up is negative

AND

• Patient has history of medical

diseases that may cause

microhematuria

• Casts are present in urine

microscopyhttps://www.studyblue.com/notes/note/n/urine-casts-cells/deck/16597911

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URINARY TRACT INFECTIONS

• SOURCES/CAUSES

• CONSTIPATION (WOMEN MORE SUSCEPTIBLE)

• INTERCOURSE

• EXPOSURE TO BACTERIA FROM POOLS, BATHTUB, LAKE, ETC.

• KIDNEY STONES

• ANATOMICAL ABNORMALITY

• URINARY TRACT OBSTRUCTION

• VESICOURETERAL REFLUX

• INCONTINENCE

• URINARY RETENTION

• RECENT INSTRUMENTATION

• CYSTOSCOPY, CATHETER, SURGERY

• ATROPHIC VAGINITIS

URINARY TRACT INFECTIONS

• SYMPTOMS

• DYSURIA

• HEMATURIA OR DISCOLORED URINE

• PELVIC PAIN

• LOW BACK PAIN

• SENSATION OF INCOMPLETE BLADDER EMPTYING

• FREQUENCY/URGENCY

• WORSENING INCONTINENCE

URINARY TRACT INFECTIONS

http://zeroinfections.blogspot.com/2012/08/urinary-tract-infections.html

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URINARY TRACT INFECTIONS

• PYELONEPHRITIS

• FEVER, UNILATERAL FLANK PAIN (CAN BE IN ADDITION TO ABOVE UTI SYMPTOMS)

• SHOULD BE TREATED URGENTLY

http://www.medicinenet.com/kidney_infection/article.htm http://www.pafmj.org/editor_images/PATTERN%20OF%20URINARY%20FIGURE1.jpg

URINARY TRACT INFECTIONS

• TREAT BASED ON CULTURE & SENSITIVITIES

• URINE CULTURES NOT ALWAYS (+) FOR PROSTATITIS AND URETHRITIS

• PRE-EMPTIVE TREATMENT

• CAN USE PRIOR C&S IF AVAILABLE TO DETERMINE ANTIBIOTIC SELECTION

• SYMPTOMATIC RELIEF

• URINARY ANALGESICS (URIBEL, PYRIDIUM, AZO)

• ALPHA BLOCKERS FOR PROSTATITIS

URINARY TRACT INFECTIONS

• COMMON BACTERIA

• E.COLI (MOST COMMON)

• KLEBSIELLA

• ENTEROCOCCUS

• PROTEUS

• PSEUDOMONAS

• STAPHYLOCOCCUS

• COMMON ANTIBIOTICS USED

• FLUOROQUINOLONES (LEVAQUIN, CIPRO)

• BACTRIM

• NITROFURANTOIN

• CEPHALOSPORINS (CEFTIN, KEFLEX)

• PENICILLINS

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URINARY TRACT INFECTIONS

• UTI PREVENTION

• HYGIENE (REGARDING GARMENTS, SEXUAL ACTIVITY)

• BOWEL MANAGEMENT

• HYDRATION

• CRANBERRY SUPPLEMENTS

• PROPHYLACTIC ANTIBIOTICS/ANTISEPTICS

• KEFLEX

• BACTRIM (OR TRIMETHOPRIM IF SULFA ALLERGY)

• NITROFURANTOIN (RISK OF PULMONARY FIBROSIS WITH CHRONIC USE)

• ADDRESSING STONES, INCONTINENCE, BLADDER EMPTYING, ANATOMICAL ABNORMALITY

• VAGINAL ESTROGEN FOR ATROPHIC VAGINITIS IN POST-MENOPAUSAL WOMEN

MICROHEMATURIA & URINARY TRACT INFECTIONS

• URINARY TRACT INFECTION (UTI) IS A POSSIBLE SOURCE OF MICROHEMATURIA

• UTI SHOULD BE SUSPECTED BASED ON SYMPTOMS AND PRIOR HISTORY

• SYMPTOMS CAN INCLUDE DYSURIA, FREQUENCY, URGENCY, PELVIC PAIN, BACK PAIN

• CONSIDER PRIOR HISTORY OF RECURRENT OR CHRONIC UTI

MICROHEMATURIA & URINARY TRACT INFECTIONS

• IF UTI IS SUSPECTED, A URINE CULTURE SHOULD BE SENT

• ANTIBIOTICS MAY BE STARTED EMPIRICALLY IF UTI IS SUSPECTED AND PATIENT IS SYMPTOMATIC

OR AT HIGH RISK FOR DEVELOPING A MORE SERIOUS INFECTION (PYELONEPHRITIS/SEPSIS)

• IF AVAILABLE, REVIEW PRIOR ANTIBIOTIC SENSITIVITIES

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MICROHEMATURIA & URINARY TRACT INFECTIONS

IN LIGHT OF GROWING ANTIBIOTIC RESISTANCE, MICROHEMATURIA SHOULD NOT BE

TREATED WITH ANTIBIOTICS UNLESS A URINARY TRACT INFECTION IS STRONGLY SUSPECTED

WHEN TO REFER TO UROLOGY?

MICROHEMATURIA

• URINE MICROSCOPY >3 RBCS

• IN-OFFICE DIPSTICK UA + ON 2 TESTS

• SUSPICIOUS IMAGING FINDINGS

• RISK FACTORS

• SMOKING HISTORY

• AGE

URINARY TRACT INFECTIONS

• RECURRENT INFECTIONS

• PERSISTENT SYMPTOMS

• SUSPECTED PYELONEPHRITIS

• UTI WITH KIDNEY STONES

• SUSPCIOUS IMAGING FINDINGS

• INCONTINENCE

• URINARY RETENTION

Aneesa Husain, PA-C

USMD Cancer Center Arlington

Arlington, TX 76017

817-417-1100

Aneesa.Husain@usmd.com