Blood in the urine
Macroscopic (frank, or gross hematuria)/ Dipstick hematuria for Microscopic hematuria (the presence of > 3 red blood cells per high power microscopic field).
Painless or painful.
Initial / Terminal / Total
Nephrological (medical) or urological (surgical)
glomerular and nonglomerular
blood dyscrasias, interstitial nephritis, and renovascular disease
Surgical/urological nonglomerular causes:
renal tumours, urothelial tumours (bladder, ureteric, renal collecting system), prostate cancer, bleeding from vascular benign prostatic enlargement, trauma, renal or ureteric stones, and UTI.
Haematuria in these situations is usually characterised by circular erythrocytes and absence of proteinuria and casts.
Anemia: bleeding is so heavy (this is rare)
Urine retention or ureteric colic (Clot retention)
Work Up :
IVU or computed tomography (CT) scan in selected groups.
Treat the cause
The commonest urologic emergency.
One of the commonest causes of the "Acute Abdomen".
Sudden onset of severe pain in the flank
Most often due to the passage of a stone formed in the kidney, down through the ureter.
The pain is characteristically :
very sudden onset
colicky in nature
Radiates to the groin as the stone passes into the lower ureter.
May change in location, from the flank to the groin, (the location of pain does not provide a good indication of the position of the stone)
The patient cannot get comfortable, and may roll around in agony.
Associated with nausea / Vomiting
the pain of a ureteric stone as being worse than the pain of labour.
Leaking abdominal aortic aneurysms
Ovarian pathology (e.g., twisted ovarian cyst)
Inflammatory bowel disease (Crohn's, ulcerative colitis)
Burst peptic ulcer
Work Up :
Examination: patient want to move around, in an attempt to find a comfortable position.
Radiological investigation :
KUB / Abdominal US
advantages over IVP:
greater specificity (95%) and sensitivity (97%) for diagnosing ureteric stones
Can identify other, non-stone causes of flank pain.
No need for contrast administration.
Faster, taking just a few minutes
the cost of CTU is equivalent to that of IVU
very accurate way of determining whether or not a stone is present in the ureter
very high cost
Acute Management of Ureteric Stones:
Intramuscular or intravenous injection, by mouth, or per rectum
+/- Opiate analgesics (pethidine or morphine).
? Hyper hydration
'watchful waiting' with analgesic supplements
95% of stones measuring 5mm or less pass spontaneously
Indications for Intervention to Relieve Obstruction and/or Remove the Stone:
Pain that fails to respond to analgesics.
Renal function is impaired because of the stone (solitary kidney obstructed by a stone, bilateral ureteric stones, or preexisting renal impairment )
Obstruction unrelieved for > 4 weeks
Personal or occupational reasons
Treatment of the Stone:
Temporary relief of the obstruction:
Insertion of a JJ stent or percutaneous nephrostomy tube.
Definitive treatment of a ureteric stone:
Open Surgery: very limited.
The kidneys relatively protected from traumatic injuries.
Considerable degree of force is usually required to injure a kidney.
Mechanisms and cause:
direct blow or acceleration/ deceleration (road traffic accidents, falls from a height, fall onto flank)
knives, gunshots, iatrogenic, e.g., percutaneous nephrolithotomy (PCNL)
Indications for renal imaging:
-Penetrating chest, flank, and abdominal wounds
-Microscopic [>5 red blood cells (RBCs) per high powered field] or dipstick hematuria a hypotensive patient (SBP <90mmHg )
-A history of a rapid acceleration or deceleration
-Any child with microscopic or dipstick hematuria who has sustained trauma.
What Imaging Study?
replaced by the contrast-enhanced CT scan
On-table IVU if patient is transferred immediately to the operating theatre without having had a CT scan and a retroperitoneal haematoma is found,
-Spiral CT: does not allowaccurate staging
can certainly establish the presence of two kidneys
the presence of a retroperitoneal hematoma
power Doppler can identify the presence of blood flow in the renal vessels.
cannot accurately identify parenchymal tears, collecting system injuries, or extravasations of urine until a later stage when a urine collection has had time to accumulate.
the imaging study of choice
accurate, rapid, images other intra-abdominal structures
American Association for the Surgery of Trauma Organ Injury Severity Scale
1. subcapsular hematoma
2. superficial tear
3. deep tear
4. deep tear+extravasation +- renal artery thrombosis
5. shattered kidney - vascular avulsion
-Over 95% of blunt injuries
-50% of renal stab injuries and 25% of renal gunshot wounds (specialized center).
.Wide Bore IV line.
. IV antibiotics.
. serial CBC (Htc)
.F/up US &/or CT.
2. Surgical exploration:
- Persistent bleeding (persistent tachycardia and/or hypotension failing to respond to appropriate fluid and blood replacement
- Expanding perirenal haematoma (again the patient will show signs of continued bleeding)
- Pulsatile perirenal haematoma
- The ureters are protected from external trauma by surrounding bony structures, muscles and other organs
Causes and Mechanisms :
- External Trauma
- Internal Trauma
- Severe force is required
- Blunt or penetrating.
- Blunt external trauma severe enough to injure the ureters will usually be associated with multiple other injuries
- Knife or bullet wound to the abdomen or chest may damage the ureter, as well as other organs.
- Uncommon, but is more common than external trauma
. Hysterectomy, oophorectomy, and sigmoidcolectomy
. Caesarean section
. Aortoiliac vascular graft placement,
. Laparoscopic procedures,
. Orthopedic operations
Requires a high index of suspicion
1. An ileus: the presence of urine within the peritoneal cavity
2. Prolonged postoperative fever or overt urinary sepsis
3. Persistent drainage of fluid from abdominal or pelvic drains, from the abdominal wound, or from the vagina.
4. Flank pain if the ureter has been ligated
5. An abdominal mass, representing a urinoma
6. Vague abdominal pain
7. The pathology report on the organ that has been removed may note the presence of a segment of ureter!
- JJ stenting
- Primary closure of partial transection of the ureter
- Direct ureter to ureter anastomosis
- Reimplantation of the ureter into the bladder (ureteroneocystostomy), either using a psoas hitch or a Boari flap
- Autotransplantation of the kidney into the pelvis
- Replacement of the ureter with ileum
- Permanent cutaneous ureterostomy