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Differential Diagnosis
of Haematuria
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Definition

 Haematuria is the passage of red blood cells in the urine. Care must
be taken to distinguish it from other causes of discoloration of urine.
All patients with haematuria must be fully investigated. If haematuria
has initially been diagnosed on dipstick testing it must always be
confirmed by microscopy.

Sumber: Andrew T Raftery, Eric Lim, Andrew J K Ostor. 2014. Differential Diagnosis on
Churchill’s Pocketbooks. UK: Churchill Livingstone
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 Hematuria is most closely related to disorders of renal or gen-


itourinary origin in which bleeding is the result of trauma or
damage to the organs of these systems. Major causes of hema-
turia include renal calculi, glomerular diseases, tumors, trauma,
pyelonephritis, exposure to toxic chemicals, and anti- coagulant
therapy.

Sumber : Strasinger, Susan K. 2008. Urinalysis & Body Fluids 5th edition.
Philadelphia: F. A. Davis Company
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Causes of Heamaturia

Sumber: Andrew T Raftery, Eric Lim, Andrew J K


Ostor. 2014. Differential Diagnosis on Churchill’s
Pocketbooks. UK: Churchill Livingstone
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Sumber : Strasinger, Susan K. 2008. Urinalysis & Body Fluids 5th edition.
Philadelphia: F. A. Davis Company
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Hemoglobinuria

 Hemoglobinuria may result from the lysis of red blood cells produced in the
urinary tract, particularly in dilute, alkaline urine.

 It also may result from intravascular hemolysis and the subsequent filtering of
hemoglobin through the glomerulus. Lysis of red blood cells in the urine
usually shows a mixture of hemoglobinuria and hematuria, whereas no red
blood cells are seen in cases of intravascular hemolysis.

 Under normal conditions, the formation of large hemoglobin- haptoglobin


complexes in the circulation prevents the glomerular filtration of hemoglobin.
When the amount of free hemoglobin present exceeds the haptoglobin
content—as occurs in hemolytic anemias, transfusion reactions, severe burns,
brown recluse spider bites, infections, and strenuous exercise—hemoglobin is
available for glomerular filtration.

Sumber : Strasinger, Susan K. 2008. Urinalysis & Body Fluids 5th edition.
Philadelphia: F. A. Davis Company
z Myoglobinuria
 Myoglobin, a heme-containing protein found in muscle tis- sue, not only reacts positively with
the reagent strip test for blood but also produces a clear red-brown urine.

 The presence of myoglobin rather than hemoglobin should be suspected in patients with
conditions associated with muscle destruction (rhabdomyolysis). Examples of these
conditions include trauma, crush syndromes, prolonged coma, convulsions, muscle-wasting
diseases, alcoholism, heroin abuse, and extensive exertion.

 The development of rhabdomylosis has been found to be a side effect in certain patients taking
the cholesterol-lowering statin medications.

 The heme portion of myoglobin is toxic to the renal tubules, and high concen- trations can
cause acute renal failure.

 The massive hemoglobinuria seen in hemolytic transfusion reactions also is associated with
acute renal failure.

Sumber : Strasinger, Susan K. 2008. Urinalysis & Body Fluids 5th edition. Philadelphia: F. A. Davis
Company
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Sumber : Strasinger, Susan K. 2008.


Urinalysis & Body Fluids 5th edition.
Philadelphia: F. A. Davis Company
z
 Hematuria yang terjadi pada laki-laki >40 tahun harus di curigai adanya
tumor dan keganasan, sedangkan pada <40 tahun baik laki-laki maupun
perempuan dapat disebabkan oleh infeksi, inflamsi, atau batu pada saluran
kemih.

 Hematuria terbagi atas hematuria masif (gross hematuria) dan hematuria


mikroskopik asimptomatik.

 Hematuria masif, yatitu terdapatnya darah di dalam urin sehingga urin


berwarna merah atau kecoklatan. Hematuria masif ini biasanya
disebabkan oleh 1 mL darah/L urin.

 Hematuria bisa disertai adanya nyeri saat berkemih, dan juga tidak.
Hematuria tanpa disertai nyeri waktu berkemih dapat disebabkan oleh
keganasan atau kelainan vaskuler.

Sumber: Setyohadi, B, et.al. 2016. EIMED PAPDI Kegawatdaruratan Penyakit


Dalam. Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia.
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 Hematuria asimptomatik (mikroskopis) adalah ditemukannya eritrosit di


dalam urin >=3/LPB pada pemriksaan 2-3 sampel urin yang diambil pada
waktu yang berbeda.

 Hematuria dapat disebabkan dengan proteinuria, karena 1 mL darah


mengandung 50 mg albumin.

 Hematuria mikroskopik dan proteinuria asimptomatik pada urinalisis


menunjukkan adanya penyakit ginjal intrinsik, glomerulusnefritis berat.

 Hematuria mikroskopik asimptomatik sering berhubungan dengan penyait


glomerular benigna, keganasan ginjal, kanker kandung kemih.

Sumber: Setyohadi, B, et.al. 2016. EIMED PAPDI Kegawatdaruratan Penyakit


Dalam. Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia.
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Low pain– heamaturia syndrome

 Suatu kelainan yang ditandai nyeri kostovertebral dan hematuria


(baik mikroskopik maupun masif), tanpa kelainan fungsi ginjal
maupun struktur saluran kemih.

 Penyebabnya tidak diketahui, dan pada pemeriksaan urologi


tidak didapatkan kelaianan yang spesifik, bahkan biopsi ginjal
dalam batas normal.
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History
 Is there pain associated with haematuria to suggest infection or
inflammation?

 Painless haematuria is usually associated with tumour or TB.

 Total haematuria (throughout the stream) suggests bleeding from


the upper urinary tract or bladder. Initial haematuria (at the start of
the stream) suggests bleeding from the urethra or the prostate.
Terminal haematuria (at the end of the stream) suggests bleeding
from the bladder or prostate.

 Check for a family history of polycystic kidney disease. There may


be a history of TB elsewhere.

Sumber: Andrew T Raftery, Eric Lim, Andrew J K Ostor. 2014. Differential Diagnosis on
Churchill’s Pocketbooks. UK: Churchill Livingstone
z
History (2)
 Bladder disease may be accompanied by suprapubic pain, frequency and
dysuria.

 Check for symptoms of prostatism, i.e. difficulty in starting, poor stream and
nocturia.

 Urethral injury will normally be apparent. It may occur following pelvic


fractures or falling astride an object.

 Is the patient on anticoagulants? Is there any history of blood dyscrasia? Is


there evidence of sickle cell disease or exposure to malaria? Strenuous
exercise may cause haematuria.

Sumber: Andrew T Raftery, Eric Lim, Andrew J K Ostor. 2014. Differential


Diagnosis on Churchill’s Pocketbooks. UK: Churchill Livingstone
z
History (3)

 Has there been any recent foreign travel (schistosomiasis)? Is there any
pain in the loin to suggest kidney disease, or a history of ureteric colic to
suggest passage of a stone or clot down the ureter?

 Has there been a recent renal biopsy? Discoloration of urine may be due to
a variety of causes. Haemoglobinuria may occur with haemolysis and
myoglobinuria following crush injuries or ischaemia of muscle.

 Check for ingestion of any substance that may change the colour of the
urine. Acute intermittent porphyria is extremely rare and is accompanied by
abdominal pain. If the urine from a patient is allowed to stand in the light it
will become purplish-red.

Sumber: Andrew T Raftery, Eric Lim, Andrew J K Ostor. 2014. Differential


Diagnosis on Churchill’s Pocketbooks. UK: Churchill Livingstone
z

 Painless haematuria suggests malignancy and requires urgent


investigation.

 Dipstick testing must always be confirmed by microscopic


examination of an MSU.

 A patient with microscopic haematuria associated with abnormal red


cell morphology and proteinuria should be referred to a nephrologist
rather than a urologist in the first instance.

Sumber: Andrew T Raftery, Eric Lim, Andrew J K Ostor. 2014. Differential


Diagnosis on Churchill’s Pocketbooks. UK: Churchill Livingstone
z
General Investigations
 FBC, ESR (erythrocyte sedimentation rate)
Hb , gross haematuria, malignancy. Hb polycythaemia associated with
hypernephroma. WCC infection. Platelets blood dyscrasias. ESR malignancy,
TB.

 Urine microscopy
Red cells (excludes haemoglobinuria and ingestion of substances that cause
discoloration of urine). White cells in infection. Organisms in infection. Cytology.

 Urea and electrolytes


Renal failure.

 Clotting screen
Anticoagulant therapy. Blood dyscrasias.

 chest X-ray
Metastases (cannonball metastases with hypernephroma). TB.

 KUB (kidney ureter bladder (plain X-ray))


Renal calculus.
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Specific Investigations

 PSA: Prostatic carcinoma.

 Sickling test: Sickle cell disease.

 IVU: Stone. Tumour. TB.

 Ultrasonography : Cystic versus solid. Stone. Urinary tract obstruction.

 CT
Tumour (confirmation and degree of invasion). Cyst. Obstructive uropathy.

 Cystoscopy
Infection. Tumour. Stone.

Sumber: Andrew T Raftery, Eric Lim, Andrew J K Ostor. 2014. Differential Diagnosis
on Churchill’s Pocketbooks. UK: Churchill Livingstone
z
Specific Investigations

 Ureteroscopy : Tumour. Obstruction.

 Selective renal angiography: Vascular malformation. Tumour.

 Renal biopsy : Glomerular disease. Tumour.

 Prostatic biopsy : Carcinoma of the prostate.

Sumber: Andrew T Raftery, Eric Lim, Andrew J K Ostor. 2014. Differential


Diagnosis on Churchill’s Pocketbooks. UK: Churchill Livingstone
z
REFERENCE

1. Andrew T Raftery, Eric Lim, Andrew J K Ostor. 2014.


Differential Diagnosis on Churchill’s Pocketbooks. UK: Churchill
Livingstone

2. Setyohadi, B, et.al. 2016. EIMED PAPDI Kegawatdaruratan


Penyakit Dalam. Perhimpunan Dokter Spesialis Penyakit
Dalam Indonesia.

3. Strasinger, Susan K. 2008. Urinalysis & Body Fluids 5th edition.


Philadelphia: F. A. Davis Company