1/30/2018 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? 1 1/30/2018 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 2 1/30/2018 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 • RADIATION CYSTITIS • KIDNEY STONES • POST-OP SURGICAL CHANGES: PROSTATE REGROWTH, • URINARY TRACT OBSTRUCTION CRYOABLATION, MESH/SLING EROSION • URETERAL STONES • BALANITIS, VAGINITIS, VAGINAL BLEEDING UPJ OBSTRUCTION, HYDRONEPHROSIS • • NEPHROLOGICAL SOURCES • URETERAL STRICTURE • BPH • URETHRAL STRICTURE • URINARY TRACT MALIGNANCY • RENAL TUMORS • BLADDER TUMORS • URETERAL TUMORS 3 1/30/2018 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 https://www.studyblue.com/notes/note/n/urine-casts-cells/deck/16597911 S:391968115970051@1470463889150/Table-4-Urinalysis-With-Urine-CS-Reflex.png 4 1/30/2018 MICROHEMATURIA URINE CULTURE http://www.sciencephoto.com/media/855408/view http://www.lbah.com/word/bladder-stones/ MICROHEMATURIA CT-IVP KIDNEY/URETERAL STONES http://www.imagingpathways.health.wa.gov.au/index.php/imaging- pathways/gastrointestinal/acute-abdomen/acute-flank-loin-pain-renal-colic MICROHEMATURIA CT-IVP UPJ OBSTRUCTION AND HYDRONEPHROSIS http://radiopaedia.org/images/1228468 5 1/30/2018 MICROHEMATURIA CT-IVP RENAL MASS INVADING COLLECTING SYSTEM http://uronotes2012.blogspot.com/2012/04/neoplastic-renal- masses-benign-adenoma.html 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 6 1/30/2018 NORMAL BLADDER TUMOR CYSTITIS http://dronuma.com.au/cystoscopy/ https://openi.nlm.nih.gov/detailedresult.php?img http://www.webpathology.com/image.asp? =PMC3725437_jmedlife-06-140-g002&req=4 case=51&n=26 URETHRAL STRICTURE BLADDER STONE BPH – PROSTATE ENLARGEMENT http://stgeorgeurology.com.au/optical- http://www.virtantiq.com/Urinary+Blad http://www.canjurol.com/article.php?ID=2357 urethrotomy der+Stone+Removal 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 7 1/30/2018 MICROHEMATURIA Test: Positive Urine Culture Diagnosis: Urinary Tract Infection Treatment: Antibiotic based on culture sensitivities http://www.lbah.com/word/bladder-stones/ 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 Test: CT scan Diagnosis: Obstructing UPJ stone Treatment: Oral medication + Hydration, Shockwave Lithotripsy (ESWL), or Ureteroscopic Laser Lithotripsy *refer to urology http://www.imagingpathways.health.wa.gov.au/index.php/imaging- pathways/gastrointestinal/acute-abdomen/acute-flank-loin-pain-renal-colic 8 1/30/2018 MICROHEMATURIA Test: CT scan Diagnosis: UPJ Obstruction and Hydronephrosis Treatment: possible options based on further work up include ureteral dilation or pyeloplasty *refer to urology http://radiopaedia.org/images/1228468 MICROHEMATURIA Test: CT scan Diagnosis: Renal Mass Invading collecting system Treatment: Radical Nephrectomy *refer to urology http://uronotes2012.blogspot.com/2012/04/neoplastic-renal- masses-benign-adenoma.html NORMAL BLADDER TUMOR CYSTITIS http://dronuma.com.au/cystoscopy/ https://openi.nlm.nih.gov/detailedresult.php?img http://www.webpathology.com/image.asp? =PMC3725437_jmedlife-06-140-g002&req=4 case=51&n=26 TURBT – TRANSURETHRAL MONITOR VS. TREAT RESECTION of BLADDER DEPENDING ON TUMOR OTHER TESTS CYSTOSCOPIC FINDINGS - Treatment 9 1/30/2018 URETHRAL STRICTURE BLADDER STONE BPH – PROSTATE ENLARGEMENT http://stgeorgeurology.com.au/optical- http://www.virtantiq.com/Urinary+Blad http://www.canjurol.com/article.php?ID=2357 urethrotomy der+Stone+Removal DILATION vs. VIU SURGICAL (Visual Internal TREATMENT MEDICAL vs. SURGICAL Urethrotomy) vs. (CYSTOLITHOLAPAXY) THERAPY (such as TURP) URETHROPLASTY CYSTOSCOPIC FINDINGS - Treatment 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 microscopy https://www.studyblue.com/notes/note/n/urine-casts-cells/deck/16597911 10 1/30/2018 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 11 1/30/2018 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 12 1/30/2018 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 13 1/30/2018 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 URINARY TRACT INFECTIONS • URINE MICROSCOPY >3 RBCS • RECURRENT INFECTIONS • IN-OFFICE DIPSTICK UA + ON 2 TESTS • PERSISTENT SYMPTOMS • SUSPICIOUS IMAGING FINDINGS • SUSPECTED PYELONEPHRITIS • UTI WITH KIDNEY STONES • RISK FACTORS • SUSPCIOUS IMAGING FINDINGS • SMOKING HISTORY • INCONTINENCE • URINARY RETENTION • AGE Aneesa Husain, PA-C USMD Cancer Center Arlington Arlington, TX 76017 817-417-1100 [email protected] 14.