Renal and Urological Emergencies




(1)
Royal Free NHS Foundation Trust, London, UK

 




Causes of red urine





  • Macroscopic haematuria


  • Haemoglobinuria (haemolysis)


  • Myoglobinuria


  • Drugs: rifampicin; metronidazole; warfarin; nitrofurantoin


  • Menstruation


  • Food: beetroot (anthrocyanin); red cabbage; blackberries; food colourants (paprika; rhodamine B)


  • Urate crystals: ‘brick dust’ in a baby’s nappy


Types of haematuria

The timing of haematuria during micturition is an aid in the localization of the source of bleeding.



  • Initial: anterior urethra


  • Terminal: posterior urethra; bladder, including neck and trigone; prostate; seminal vesicles


  • Total: bladder; upper urinary tract (kidney or ureter)


Checklist for haematuria assessment





  • Timing: initial, total, terminal


  • Lower urinary tract symptoms: dysuria, increased urinary frequency, urgency, urethral discharge


  • Obstructive urinary symptoms: hesitancy, straining to void, sensation of incomplete emptying


  • Flank pain: renal stone disease; pyelonephritis


  • Suprabic pain: bladder outlet obstruction; haemorrhagic cystitis


  • Signs associated with glomerular origin: peripheral and periorbital oedema; oliguria; hypertension; weight gain


  • Features of vasculitis: skin rash; arthralgia; fever


  • Recent urological intervention, such as bladder catheterization, prostate biopsy, ureteral stent placement, nephrostomy, or trans-urethral surgery


  • Drug history: anticoagulants; nephrotoxic medications (eg NSAIDs)


  • Family history of renal disease


  • Occupational history: exposure to chemicals and smoking


  • Travel history


  • Urine dip stick analysis for blood, protein, leucocytes, nitrites. Dipstick tests do not distinguish between intact red blood cells, free haemoglobin or free myoglobin.


  • Urine microscopy for red blood cells; red cell casts; dysmorphic red blood cells. Three or more red blood cells per high power field on at least two out of three correctly collected urine specimens indicates microscopic haematuria.


  • Renal function: plasma creatinine/eGFR


  • Upper urinary tract imaging: CT scan


Red flags with haematuria





  • Painless macroscopic haematuria (which has a high diagnostic yield for urological malignancy)


  • Symptomatic microscopic haematuria in absence of urinary tract infection


  • Unexplained microscopic haematuria in patient aged >50 years


Causes of haematuria

Glomerular disease



  • IgA nephropathy (Berger’s disease)


  • Acute post-infectious glomerulonephritis (nephritogenic strains of Group A streptococcus) (hypertension; skin rash)


  • Alport’s syndrome (hereditary nephritis)


  • Membrano-proliferative glomerulonephritis


  • Systemic vasculitis/ lupus


  • Thin glomerular basement membrane disease (benign familial haematuria)


  • Rapidly progressive glomerulonephritis

Non-glomerular



  • Upper urinary tract (kidney and ureter)



    • Tumours: renal cell carcinoma; transitional cell carcinoma.


    • Medullary/ interstitial disease: papillary necrosis; medullary sponge kidney; tuberculosis


    • Urolithiasis


    • Trauma to kidneys/ureters


    • Miscellaneous



      • Arterio-venous malformation


      • Loin pain-haematuria syndrome (recurent loin pain and intermittent macroscopic or microscopic haemturia); nutcracker syndrome (compression of left renal vein between abdominal aorta and superior mesenteric artery)


      • Renal artery thrombosis


      • Hereditary haemorrhagic telangiectasia


  • Lower urinary tract (bladder and urethra)



    • Bladder: haemorrhagic cystitis; transitional cell carcinoma; stone; schistosomiasis; radiation cystitis


    • Prostate: benign prostatic hyperplasia; cancer; prostatitis


    • Urethra: urethritis


    • Coagulopathies: anticoagulants; haemophilia; sickle cell disease


Features suggesting glomerular origin of haematuria

A fresh, midstream, clean-catch or cather specimen of urine should be analysed



  • Smoky brown coloured urine; no clots


  • Red blood cell casts


  • Dysmorphic red blood cells


  • Significant proteinuria (>500 mg/24 h)


Risk factors for urothelial cancer presenting with haematuria





  • Age > 40 years


  • Male gender


  • History of cigarette smoking, past or current


  • History of occupational chemical or dye exposure (aromatic amines, benzenes)


  • Cyclophosphamide therapy


  • History of pelvic radiation


  • Chronic irritative voiding lower urinary tract symptoms (urgency, frequency, dysuria, nocturia, hesitancy, sensation of incomplete emptying)


  • Prior urological disease or treatment


  • Chronic indwelling foreign body


Retention of urine

Urinary retention can be acute or chronic. Acute urinary retention refers to the sudden inability to pass urine and empty the bladder during voluntary voiding.


Causes of acute urinary retention

Anatomical causes resulting in mechanical obstruction to the flow of urine



  • Penis: phimosis; paraphimosis; foreign body constriction


  • Urethra: foreign body, calculus; urethritis; stricture; tumour; thrombosed urethral caruncle; meatal stenosis; pelvic trauma with disruption of posterior urethra or bladder neck; peri-urethral abscess


  • Extrinsic compression: pelvic mass (gynaecological malignancy, ovarian cyst, uterine fibroid); pelvic organ prolapse (cystocele, rectocele, uterine prolapse); haematoma; retroverted impacted gravid uterus; faecal impaction (causing pressure on the bladder trigone)


  • Prostate: benign prostatic hyperplasia; cancer; prostatitis; bladder neck contracture; prostatic infarction; prostatic abscess

Neuropathic Causes



  • Motor/paralytic: spinal shock; spinal cord syndromes; cauda equina syndrome


  • Sensory/ paralytic: diabetes mellitus; multiple sclerosis; spinal cord syndromes

Drugs causing dynamic obstruction to urine flow: anticholinergic, anti-spasmodic, tricyclic antidepressants, alpha-adrenergic agonists, antihistamines, opiates, anti-psychotics.

Infective/inflammatory: urinary tract infection; acute vulvovaginitis; genital herpes.


Causes of acute urinary retention in women

Neurological:



  • Diabetes mellitus


  • Multiple sclerosis


  • Spinal cord lesions: trauma, tumours


  • Transverse myelitis


  • Cerebrovascular accident


  • Fowler’s syndrome: impaired relaxation of external sphincter in post-menopausal women

Non-neurological:



  • Urethral Obstruction:



    • Cystocoele; rectocoele; uterine prolapse


    • Stricture; diverticulum


    • Previous incontinence surgery


    • Herpetic vulvo-vaginitis


    • Previous total abdominal hysterectomy


Lower urinary tract symptoms in men which can be predictive for the development of acute urinary retention





  • Storage symptoms: frequency; urgency; nocturia; incontinence


  • Voiding symptoms: slow stream; spraying; intermittent flow; terminal dribbling


  • Post-micturition symptoms: incomplete emptying; dribbling


Urinary retention checklist





  • Time of last voiding


  • Previous episodes of acute urinary retention


  • Preceding lower urinary tract symptoms


  • Haematuria, leading to clot retention


  • Neurological symptoms and signs


  • Drug history


  • Constipation


  • Recent abdominal or pelvic surgery


  • Bladder distension, recognized by a palpable tender suprapubic mass and confirmed on bedside ultrasound scan


  • Urine dip stick analysis


  • Renal function


  • Bladder ultrasound for residual urine post-voiding


  • Digital rectal examination after catherisation to evaluate anal tone, size and texture of the prostate, presence of faecal impaction


Complications of long-term indwelling urethral catheters presenting in emergency practice





  • Blocked catheter: encrustation (crystal precipitation), often associated with urease-producing bacteria (Proteus mirabilis); kinks; stones


  • Infection (asymptomatic bacteriuria; urethritis; cystitis; pyelonephritis; seminal vesiculitis; epididymo-orchitis; bacteraemia; urosepsis). Catheter-related infection can present with



    • Fever < 38.4 degrees centigrade


    • Unusually cloudy urine


    • Mental state changes


    • More frequent catheter blockage


    • Increased detrusor spasms


    • Hypotension


    • >5–10 WBCs per high-power field on microscopy


  • Gross haematuria


  • Leakage of urine (bypassing) around catheter: detrusor overactivity causing spasms (overactive bladder, cystitis, bladder outlet obstruction) (may respond to anticholinergic medication); catheter blockage


  • Failure of balloon deflation: secondary lumen obstruction; valve malfunction (cut off side-arm and remove valve)


  • Paraphimosis


Causes of renal pain

Urinary obstruction



  • Calculus


  • Necrotic papilla


  • Blood clot


  • Tumour


  • Pelvi-ureteric junction dyssynergia

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Nov 20, 2017 | Posted by in Uncategorized | Comments Off on Renal and Urological Emergencies

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