The Approach to the Patient with Hematuria

The Effects of Diet, Dietary Supplements, Drugs and Exercise on Physical, Diagnostic Values of Urine Characteristics

Background/Objectives: This review summarizes the current knowledge about factors that affect the physical characteristics of urine. It highlights proper urine sample collection and displays factors like diet, hydration status, and medications that can alter urine color, odor, clarity, specific gravity and pH. Results: Urinalysis is a minimally invasive examination of a patient's health, especially concerning nephrological and endocrinological abnormalities, as well as dietary habits and stimulants used. Certain deviations in appearance, composition or frequency/pain during urination may indicate an ongoing disease process in the body. Based on laboratory results, further medical treatment is determined. The reason for a change in the color of the urine, for its clouding or intense odor may be a disease, as well as the consumption of food, medication, intensive physical exercise or inadequate hydration of the body. Well-standardized procedures for collecting, transporting, preparing and analyzing samples should become the basis for an effective diagnostic strategy in urinalysis. It is worth noting that pharmacists in pharmaceutical care are often the first people to whom a patient turns for health advice and for the interpretation of simple laboratory tests. Acquiring the ability to interpret the results of laboratory tests and the principles of proper sampling for laboratory tests is indispensable in the process of possible counseling and providing reliable answers to patients' questions. Conclusions: Although urinalysis is not recommended as a routine screening tool for the general population, it can prove to be a valuable source of patient health data in some cases as the data will be useful to physicians and pharmacists to more effectively diagnose and better care for patients.

The impact of age, sex, comorbidities, and use of antithrombotics on the clinical course severity among patients surgically treated for urinary bladder tamponade

Objectives

To examine the relationship between clinical patient characteristics and the severity of the disease course in patients hospitalized due to urinary bladder tamponade. The severity was assessed based on hemoglobin (Hgb) levels upon admission, the requirement for red blood cell transfusion (RBCT), and length of hospital stay.

Materials and Methods

A retrospective analysis was conducted at a single center, involving 75 patients who were hospitalized due to urinary bladder tamponade.

Results

Bladder cancer (33.3%) and postoperative bleeding (28%) were the most common causes of bladder tamponade. Patient age exhibited a negative correlation with Hgb levels upon admission (r = -0.539, P < 0.001) and a positive correlation with the quantity of administered RBCT units (r = 0.425, P < 0.001) and the length of hospitalization (r = 0.541, P < 0.001). The number of comorbidities exhibited a negative correlation with Hgb levels upon admission (r = -0.555, P < 0.001) and a positive correlation with the quantity of administered RBCT units (r = 0.522, P < 0.001) and the length of hospitalization (r = 0.543, P < 0.001). Patients taking antithrombotic therapy (AT) had lower mean Hgb levels on admission (87.8 ± 13.5 g/L vs. 107.6 ± 18.7 g/L, P < 0.001), a higher mean number of administered RBCT units (2.8 ± 2.1 vs. 1.1 ± 1.3, P < 0.001) and longer hospitalizations (4.6 ± 1.6 days vs. 3.1 ± 1.1 days, P < 0.001) compared to those not taking AT.

Conclusion

Older patients with multiple comorbidities, particularly those taking AT, should be expected to have a more severe clinical course of bladder tamponade. Therefore, special clinical attention is necessary for this vulnerable patient group.

Gross hematuria: Renal cell carcinoma mimicking a renal arteriovenous malformation

The differential diagnosis between renal arteriovenous malformations (AVM) and cancer may be a challenge, due to the similar clinical and imaging findings. Herein, we report the case of an 80-year-old male patient presenting gross hematuria, initially diagnosed and treated with embolization for a renal AVM. Due to the recurrence of hematuria and rapid progression and changes of the vascular lesion with detection also of an intralesional solid nodule, a radical nephrectomy was performed revealing the presence of a renal cell carcinoma (RCC). Renal cell carcinoma and renal AVM can be difficult to differentiate from one another, for this reason a short-term follow-up should be carried out in patients diagnosed and treated for renal AVM to confirm the resolution of AVM or to assess any changes, such as atypical neovascularization or intralesional renal masses, which may increase the suspect of a hidden renal tumor.

Predictive Factors for Major Complications and Urological Cancer Diagnosis in Older Adults (≥80 Years) Admitted to the Emergency Department for Hematuria

Background: Gross Hematuria is a relevant cause of admission to the emergency department in the general population and particularly in older adults (≥80 years). This specific urological symptom is often underestimated and usually associated with benign conditions such as urinary infections or poor hydration. Nevertheless, hematuria could lead to severe acute complications or be the first symptom of urological cancers. Methods: We retrospectively analyzed clinical data from 1169 patients aged ≥80 years consecutively admitted to the emergency department for hematuria. The primary endpoint of the study was to identify risk factors for major complications, and the secondary endpoint was to analyze risk factors for urological cancer diagnosis. The median age was 85 years (IQR 82-88 years), and 908 (77%) were males. Among them, 449 (38.4%) had a past medical history of urological neoplasm (kidney, ureter, bladder, prostate, or urethral cancer). Results: Overall, 87 patients (7.4%) had major complications (patient death, septic shock, and admission to the intensive care unit). Worse vital signs at admission, fever, and confusion (p < 0.001, OR 18.0 IC 95% [5.5-58.7]; p = 0.015, OR 2.0 IC 95% [1.1-3.5]; p = <0.001, OR 4.2 IC 95% [1.9-3.5], respectively), as well as lower hemoglobin values and higher Charlson comorbidity index (p < 0.001, OR 0.8 IC 95% [0.7-0.9]), p = 0.002, OR = 1.2 [1.1-1.3]) were independent predictive factors for major complications. The multivariate analysis identified as risk factors for diagnosis of urological cancer older age, male sex and higher comorbidity (OR 1.05 IC95% [1-1.09]; OR 2.19 IC95% [1.42-3.39] and OR 1.11 IC95% [1.2-1.2], respectively); interestingly the presence of indwelling vesical catheter (IVC) (OR 0.44 IC95% [0.24-0.82]) resulted as an independent factor for absence of urological cancers. Conclusions: Hematuria is a frequent symptom in older adults admitted to the emergency department. While this is often associated with benign conditions, there are some risk factors for major complications and for urological cancer that must be taken into account to identify the patients who need further evaluation or prompt hospital admission.

Impact of intravesical administration of tranexamic acid on gross hematuria in the emergency department: A before-and-after study

INTRODUCTION

Local applications of tranexamic acid (TXA) have been effective in treating various hemorrhagic conditions. In patients with gross hematuria, the main treatment in the emergency department (ED) is continuous bladder irrigation (CBI). However, CBI has no pharmacological effects except blood clot removal from dilution. The aim of this study was to evaluate the impact of the intravesical TXA injection before CBI.

METHODS

This study was a before-and-after, retrospective, and single-center study. The target population was hematuria patients who received CBI via a 3-way Foley catheter. As the intervention procedure, 1000 mg of TXA was injected through the Foley catheter and after 15 min, the Foley catheter was declamped and CBI started. Since the intervention started in March 2022, the patients from March 2022 to August 2022 were assigned to the after group and the patients from March 2021 to August 2021 were assigned to the before group. The primary outcomes were the length of stay in the ED and duration of Foley catheter placement. The secondary outcomes were the admissions and the revisits for CBI within 48 h after discharge.

RESULTS

The numbers of patients in the before group and after group were 73 and 86, respectively. The median length of stay in the ED was shorter in the intervention group than in the group not treated with TXA (274 min vs. 411 mins, P < 0.001). The median duration of Foley catheter placement was also shorter in the intervention group than not treated with TXA (145 min vs. 308 mins, P < 0.001). The revisits after ED discharge were lower in the after group than in the before group (2.3% vs. 12.3%, P = 0.031). There was a trend for lower admissions in the TXA treatment group than before group (29.1% vs. 45.2%, P = 0.052).

CONCLUSION

After the TXA intervention, reduction in the length of stay in the ED, the duration of Foley catheter placement, and the revisits after ED discharge was observed.

Safety and efficacy of intravesical epinephrine instillation in patients with intractable lower urinary tract hematuria - A novel approach

OBJECTIVES

To treat intractable hematuria with intravesical instillation of epinephrine.

METHODS

Sixty patients were treated with intravesical instillation of epinephrine at Mackay Memorial Hospital. The control group was composed of 60 patients who were treated with standard-of-care cystoscopic electrocautery fulguration. Under general anesthesia, epinephrine-treated group were injected with 150 mL of diluted epinephrine (1:10,000) through cystoscopy, followed by bladder irrigation with 1:100,000-diluted epinephrine at the ward. Successful hemostasis was defined as hematuria resolution within 1 month post-treatment without additional invasive procedures.

RESULTS

In the 60 patients who underwent intravesical instillation of epinephrine, radiation cystitis was the most common etiology (65.0%). Fifty-two patients (86.7%) required no additional therapy within 1 month after one course of intravesical epinephrine instillation treatment compared with 28 patients (46.7%) in the electrocautery fulguration-control group (p < 0.001). We observed a significant decrease in both the median length of hospitalization (p = 0.049) and the need for additional invasive procedures (p < 0.001) in the epinephrine group. In addition, cardiopulmonary monitoring of mean blood pressure, mean heart rate, and mean respiratory rate demonstrated no significant differences after epinephrine treatment.

CONCLUSIONS

In this study, intravesical instillation of epinephrine was an innovative method of hemostasis for intractable lower urinary tract hematuria with a success rate of 86.7%, compared to 46.7% in the control group, and significantly reduced the number of additional procedures required and the length of hospitalization. It was well tolerated by all patients, and was a safe and effective treatment modality for intractable hematuria or bladder hemorrhage.

Automated urine sediment analyzers underestimate the severity of hematuria in glomerular diseases

Hematuria, either glomerular or extraglomerular, is defined as 3 or more red blood cells (RBCs)/high power field. Currently, urinalyses are commonly performed using automated urine sediment analyzers. To assess whether RBC counting by automated urine sediment analyzers is reliable for defining hematuria in glomerular disease, random specimen urinalyses of men with nephritic glomerular disease (7674 urinalyses) and bladder cancer (12,510 urinalyses) were retrospectively reviewed. Urine RBCs were counted by an automated urine sediment analyzer based on flow cytometry (UF-1000i, Sysmex Corporation) or digital image analysis (Cobas 6500, Roche Diagnostics GmbH). In about 20% of urine specimens, the specific gravity was less than 1.010, making the RBC counts unreliable. In the urine specimens with specific gravity ≥ 1.010, RBC counts measured using either UF-1000i or Cobas 6500 were well correlated with the positive grades in the dipstick blood test. However, at a trace, 1+, or higher positive dipstick tests for blood, RBC counts were graded significantly lower in glomerular disease than in bladder cancer. The findings suggest that RBC counting by UF-1000i or Cobas 6500 underestimates the severity of hematuria in glomerular disease, possibly because dysmorphic RBCs in glomerular disease are susceptible to hemolysis and/or fail to be properly recognized.

Genitourinary Emergencies in Older Adults

Older adults are frequently seen in the emergency department for genitourinary complaints, necessitating that emergency physicians are adept at managing a myriad of genitourinary emergencies. Geriatric patients may present with acute kidney injury, hematuria, or a urinary infection and aspects of how managing these presentations differs from their younger counterparts is emphasized. Older adults may also present with acute urinary retention or urinary incontinence as a result of genitourinary pathology or other systemic etiologies. Finally, genital complaints as they pertain to older adults are briefly highlighted with emphasis on emergent management and appropriate referrals.

Complications and side effects of high-dose-rate prostate brachytherapy

PURPOSE

To describe technical challenges and complications encountered during and after high-dose-rate prostate brachytherapy (HDR-BT) and review management of these complications.

METHODS AND MATERIALS

The authors performed a systematic review of the literature on toxicities encountered after prostate HDR-BT +/- external beam radiotherapy. A total of 397 studies were identified, of which 64 were included. A focused review of literature regarding the management of acute and late toxicities also performed.

RESULTS

Most acute toxicities include grade 0-2 genitourinary and gastrointestinal toxicity. Overall, Grade 3+ Common Terminology Criteria for Adverse Events toxicity after HDR-BT was low [genitourinary: 0-1%; gastrointestinal 0-3%]. Rates of fistula formation were <1%, and radiation cystitis/proctitis were <14% and more commonly reported in cohorts treated with HDR-BT boost and external beam radiotherapy.

CONCLUSIONS

HDR-BT both as monotherapy or combined with external beam radiotherapy for prostate cancer is well tolerated. Serious complications are rare.

Role of imaging in visceral vascular emergencies

Differential diagnosis in non-traumatic acute abdomen is broad and unrelated diseases may simulate each other from a clinical perspective. Despite the fact that they are not as common, acute abdominal pain due to diseases related to visceral vessels may be life-threating if not detected and treated promptly. Thrombosis, dissection, and aneurysm in the abdominal visceral arteries or thrombosis in visceral veins may cause acute abdominal pain. Imaging with appropriate protocoling plays a fundamental role in both early diagnosis and determination of the treatment approach in these cases where early treatment can be life-saving. Computed tomography (CT) appears to be the most effective modality for the diagnosis as it provides high detail images in a very short time. Patient cooperation is also a less concern as compared to magnetic resonance imaging (MRI). As the imaging findings may sometimes be really subtle, diagnosis may be difficult especially to inexperienced imagers. Correct protocoling is also very critical to detect arterial abnormalities as visceral arterial abnormalities may not be detectable in portal phase only abdominal CT scans. In this article, we aimed to increase awareness among imaging specialists to these not very common causes of acute abdomen.

Is the kidney a target of SARS-CoV-2?

The new disease produced by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) represents a major pandemic event nowadays. Since its origin in China in December 2019, there is compelling evidence that novel SARS-CoV-2 is a highly transmissible virus, and it is associated to a broad clinical spectrum going from subclinical presentation to severe respiratory distress and multiorgan failure. Like other coronaviruses, SARS-CoV-2 recognizes human angiotensin-converting enzyme 2 as a cellular receptor that allows it to infect different host cells and likely disrupts renin-angiotensin-aldosterone system homeostasis. Particularly, a considerable incidence of many renal abnormalities associated to COVID-19 has been reported, including proteinuria, hematuria, and acute kidney injury. Moreover, it has been recently demonstrated that SARS-CoV-2 can infect podocytes and tubular epithelial cells, which could contribute to the development of the aforementioned renal abnormalities. In this review, we discuss the biological aspects of SARS-CoV-2 infection, how understanding current knowledge about SARS-CoV-2 infection may partly explain the involvement of the kidneys in the pathophysiology of COVID-19, and what questions have arisen and remain to be explored.