May 6, 2012

Image of The Day 9: Traumatic Haematuria

Gross haematuria with blood clot in tubing after the insertion of CBD. at this moment, no need to do anything yet as the cause is obvious. if the bleeding continues, then proceed with irrigation. 

Walking through the ward, you will come across a patient with Folley’s catheter and CBD bag connected to it. Haematuria as i have being described in Image of The Day 7: Renal Mass [link] could be a disaster as it is due to the neoplasm. However, it is only one out of more than 30 spectrum of disease that resulting from systemic, kidney, ureter, bladder and urethra. For today’s image of the day, i will discuss on traumatic haematuria.

In patient with already pre-existing catheter, the first thing that should come into your mind is a traumatic haematuria secondary to catheter insertion. Apart from the direct trauma due to the technique, the catheter itself can sometime cause irritation to bladder mucosa in certain patient. It is usually mild and not require any intervention. All you need to do is to observe the condition and KIV for bladder irrigation if not resolving.

In patient with no pre existing catheter who presented with hematuria, take note on these things. 1) To obtain information about any surgical procedure that patient has undergone. Patient with stenting placement post cystoscopy may cause minor bleeding. 2) History of transurethral resection of the prostate and bladder tumor resection may explain the hematuria. 3) Patient undergone laparotomy or pelvic surgery especially in obstetric and gynecology case may have iatrogenic injury to the bladder and ureter during the manipulation.

Last in the list for traumatic haematuria is  trauma associated injury. Bear in minds that all trauma patient must be inspected for bleeding from urethra meatus. While monitoring for urine output is crucial for trauma patient, Folley’s catheter insertion is an absolute contraindication for this type of patient until retrograde urethrogram has being performed to exclude urethral injury. Hematuria in trauma patient may be due to renal parenchymal injury or secondary injury to either bladder or urethra due to pelvic fracture.

Differential diagnosis of non traumatic haematuria (will not going to be discussed in this entry) would be URINARY TRACT INFECTION, stone, tumor, anticoagulation, structural abnormalities (especially polycystic kidney), prostate lesion, glomerulonephritis, enterovesical fistula, vascular pathology (renal infarction, renal vein thrombosis, AVM), renal papillary necrosis, hemorrhagic cystitis (a/w cyclophosphamide, chemotherapy with cytoxan), radiation cystitis, connective tissue disease, tuberculosis, sickle cell disease, contamination from menses and benign essential heamaturia.

When you examine the patient, look for any discoloration of the flank or suprapubic area, any bloody discharge from urethra, “free floating prostate” on per rectal examination that indicate urethral disruption and pelvic examination to rule out co –existence/ source with cervical bleeding.

Investigation should be ordered as according to the most likely diagnosis and aetiology. Routine examination would be FBC, coagulation study, UFEME (most of the time shows RBC only. But look for the present of cast as well), BUSE. Other radiological investigation may include plain abdominal x ray, retrograde urethrogram, KUB Ultrasound cytoscopy. 

If the haematuria is not associated with urethral injury and the haematuria is gross, then put the three way catheter and irrigate with at least 6 pints of Normal Saline/ 24 hours and re evaluate the patient. Non resolving haematuria will require further irrigation and detailed evaluation. Anti fibrinolytic agent like Tranexamic acid can be used in life threatening or severe haematuria before proceed with invasive modality.
Finally, please remember that even though that the haematuria is likely due to trauma in origin, please NEVER FORGET about the non trauma cause of haematuria. Think a way to exclude them! And always remember that UTI is also a common cause of Haematuria in patient with CBD and female!!

Reference: Alan T. Lefor, Leonard G. Gomella et al, “Surgery On Call”, 4th edition, Lange, 2006.

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