PEDIATRIC TIP Black children appear to be at greater risk for peritonitis.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Acute poststreptococcal glomerulonephritis:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
APSGN results from the entrapment and collection of antigen-antibody (produced as an immunologic mechanism in response to streptococcus) in the glomerular capillary membranes, inducing inflammatory damage and impeding glomerular function. Sometimes, the immune complement further damages the glomerular membrane. The damaged and inflamed glomerulus loses the ability to be selectively permeable, and allows red blood cells (RBCs) and proteins to filter through as the glomerular filtration rate (GFR) falls. Uremic poisoning may result.
APSGN is most common in males ages 3 to 7, but it can occur at any age. Incidence is rising in the United States and Europe, with epidemics occurring in developing countries in Africa, the West Indies, and the Middle East.
Up to 95% of children and up to 70% of adults with APSGN recover fully; the rest may progress to chronic renal failure within months.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Chronic glomerulonephritis:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
Common causes of chronic glomerulonephritis include primary renal disorders, such as membranoproliferative glomerulonephritis, membranous glomerulopathy, focal glomerulosclerosis, rapidly progressive glomerulonephritis and, less often, poststreptococcal glomerulonephritis. Systemic disorders that may cause chronic glomerulonephritis include lupus erythematosus, Goodpasture’s syndrome, or hemolytic-uremic syndrome.
Chronic glomerulonephritis is twice as common in males as it is in females.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Hematuria:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Appendicitis
About 15% of patients with appendicitis have either microscopic or macroscopic hematuria accompanied by bladder tenderness, dysuria, and urinary urgency. More typical findings include constant right-lower-quadrant pain (especially over McBurney’s point), nausea and vomiting, anorexia, abdominal rigidity, rebound tenderness, constipation, tachycardia, and low-grade fever.
Bladder cancer
A primary cause of gross hematuria in men, bladder cancer may also produce pain in the bladder, rectum, pelvis, flank, back, or leg. Other common features are nocturia, dysuria, urinary frequency and urgency, vomiting, diarrhea, and insomnia.
Bladder trauma
A characteristic finding in traumatic rupture or perforation of the bladder, gross hematuria is typically accompanied by lower abdominal pain. The patient may also develop anuria despite a strong urge to void; swelling of the scrotum, buttocks, or perineum; and signs of shock, such as tachycardia and hypotension.
Calculi
Both bladder and renal calculi produce hematuria, which may be associated with signs of urinary tract infection, such as dysuria and urinary frequency and urgency. Bladder calculi may also cause gross hematuria, referred pain to the lower back or penile or vulvar area and, occasionally, bladder distention.
Renal calculi may produce microscopic or gross hematuria. The cardinal symptom, though, is colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia when a calculus is passed. The pain may be excruciating at its peak. Other signs and symptoms may include nausea and vomiting, restlessness, fever, chills, abdominal distention and, possibly, decreased bowel sounds.
Coagulation disorders
Macroscopic hematuria is commonly the first sign of hemorrhage in coagulation disorders, such as thrombocytopenia or disseminated intravascular coagulation. Among other features are epistaxis, purpura (petechiae and ecchymosis), and signs of GI bleeding.
Cortical necrosis (acute)
Accompanying gross hematuria in this renal disorder are intense flank pain, anuria, leukocytosis, and fever.
Cystitis
Hematuria is a telling sign in all types of cystitis. Bacterial cystitis usually produces macroscopic hematuria with urinary urgency and frequency, dysuria, nocturia, and tenesmus. The patient complains of perineal and lumbar pain, suprapubic discomfort, and fatigue and occasionally has a low-grade fever.
More common in women, chronic interstitial cystitis occasionally causes gross hematuria. Associated features include urinary frequency, dysuria, nocturia, and tenesmus. Both microscopic and macroscopic hematuria may occur in tubercular cystitis, which may also cause urinary urgency and frequency, dysuria, tenesmus, flank pain, fatigue, and anorexia. Viral cystitis usually produces hematuria, urinary urgency and frequency, dysuria, nocturia, tenesmus, and fever.
Diverticulitis
When this disorder involves the bladder, it usually causes microscopic hematuria, urinary frequency and urgency, dysuria, and nocturia. Characteristic findings include left-lower-quadrant pain, abdominal tenderness, constipation or diarrhea and, occasionally, a palpable, firm, fixed, and tender abdominal mass. The patient may also develop mild nausea, flatulence, and a low-grade fever.
Endocarditis (subacute infective)
Occasionally, this disorder produces embolization, resulting in renal infarction and microscopic or gross hematuria. Common related findings are constant fever, chills, night sweats, fatigue, pallor, anorexia, weight loss, polyarthralgia, petechiae, flank pain, severe back pain, stiff neck, cardiac murmurs, tachycardia, and splenomegaly.
Glomerulonephritis
Acute glomerulonephritis usually begins with gross hematuria that tapers off to microscopic hematuria and RBC casts, which may persist for months. It may also produce oliguria or anuria, proteinuria, mild fever, fatigue, flank and abdominal pain, generalized edema, increased blood pressure, nausea, vomiting, and signs of lung congestion, such as crackles and a productive cough.
Chronic glomerulonephritis usually causes microscopic hematuria accompanied by proteinuria, generalized edema, and increased blood pressure. Signs and symptoms of uremia may also occur in advanced disease.
Nephritis (interstitial)
Typically, this infection causes microscopic hematuria. However, some patients with acute interstitial nephritis may develop gross hematuria. Other findings are fever, maculopapular rash, and oliguria or anuria. In chronic interstitial nephritis, the patient has dilute—almost colorless—urine that may be accompanied by polyuria and increased blood pressure.
Nephropathy (obstructive)
This disorder may cause microscopic or macroscopic hematuria, but urine is rarely grossly bloody. The patient may report colicky flank and abdominal pain, CVA tenderness, and anuria or oliguria that alternates with polyuria.
Polycystic kidney disease
This hereditary disorder may cause recurrent microscopic or gross hematuria. It commonly produces no symptoms before age 40 but may cause increased blood pressure, polyuria, dull flank pain, and signs of urinary tract infection, such as dysuria and urinary frequency and urgency. Later, the patient develops a swollen, tender abdomen and lumbar pain that’s aggravated by exertion and relieved by lying down. He may also have proteinuria and colicky abdominal pain from the ureteral passage of clots or calculi.
Prostatic hyperplasia (benign)
About 20% of patients with an enlarged prostate have macroscopic hematuria, usually when a significant obstruction is present. The hematuria is usually preceded by diminished urinary stream, tenesmus, and a feeling of incomplete voiding. It may be accompanied by urinary hesitancy, frequency, and incontinence; nocturia; perineal pain; and constipation. Inspection reveals a midline mass representing the distended bladder; rectal palpation reveals an enlarged prostate.
Prostatitis
Whether acute or chronic, prostatitis may cause macroscopic hematuria, usually at the end of urination. It may also produce urinary frequency and urgency and dysuria followed by visible bladder distention.
Acute prostatitis also produces fatigue, malaise, myalgia, polyarthralgia, fever with chills, nausea, vomiting, perineal and low back pain, and decreased libido. Rectal palpation reveals a tender, swollen, boggy, firm prostate.
Chronic prostatitis commonly follows an acute attack. It may cause persistent urethral discharge, dull perineal pain, ejaculatory pain, and decreased libido.
Pyelonephritis (acute)
This infection typically produces microscopic or macroscopic hematuria that progresses to gross hematuria. After the infection resolves, microscopic hematuria may persist for a few months. Related signs and symptoms include persistent high fever, unilateral or bilateral flank pain, CVA tenderness, shaking chills, weakness, fatigue, dysuria, urinary frequency and urgency, nocturia, and tenesmus. The patient may also exhibit nausea, vomiting, anorexia, and signs of paralytic ileus, such as hypoactive or absent bowel sounds and abdominal distention.
Renal cancer
The classic triad of signs and symptoms includes gross hematuria; dull, aching flank pain; and a smooth, firm, palpable flank mass. Colicky pain may accompany the passage of clots. Other findings include fever, CVA tenderness, and increased blood pressure. In advanced disease, the patient may develop weight loss, nausea and vomiting, and leg edema with varicoceles.
Renal infarction
Typically, this disorder produces gross hematuria. The patient may complain of constant, severe flank and upper abdominal pain accompanied by CVA tenderness, anorexia, and nausea and vomiting. Other findings include oliguria or anuria, proteinuria, hypoactive bowel sounds and, a day or two after the infarction, fever and increased blood pressure.
Renal papillary necrosis (acute)
This disorder usually produces gross hematuria, which may be accompanied by intense flank pain, CVA tenderness, abdominal rigidity and colicky pain, oliguria or anuria, pyuria, fever, chills, vomiting, and hypoactive bowel sounds. Arthralgia and hypertension are common.
Renal trauma
About 80% of patients with renal trauma have microscopic or gross hematuria. Accompanying signs and symptoms may include flank pain, a palpable flank mass, oliguria, hematoma or ecchymosis over the upper abdomen or flank, nausea and vomiting, and hypoactive bowel sounds. Severe trauma may precipitate signs of shock, such as tachycardia and hypotension.
Renal tuberculosis
Gross hematuria is often the first sign of this disorder. It may be accompanied by urinary frequency, dysuria, pyuria, tenesmus, colicky abdominal pain, lumbar pain, and proteinuria.
Renal vein thrombosis
Gross hematuria usually occurs in this type of thrombosis. In an abrupt venous obstruction, the patient experiences severe flank and lumbar pain as well as epigastric and CVA tenderness. Other features include fever, pallor, proteinuria, peripheral edema and, when the obstruction is bilateral, oliguria or anuria and other uremic signs. The kidneys are easily palpable. Gradual venous obstruction causes signs of nephrotic syndrome, proteinuria and, occasionally, peripheral edema.
Schistosomiasis
This infection usually causes intermittent hematuria at the end of urination. It may be accompanied by dysuria, colicky renal and bladder pain, and palpable lower abdominal masses.
Sickle cell anemia
In this hereditary disorder, gross hematuria may result from congestion of the renal papillae. Associated signs and symptoms may include pallor, dehydration, chronic fatigue, polyarthralgia, leg ulcers, dyspnea, chest pain, impaired growth and development, hepatomegaly and, possibly, jaundice. Auscultation reveals tachycardia and systolic and diastolic murmurs.
Systemic lupus erythematosus
Gross hematuria and proteinuria may occur when this disorder involves the kidneys. Cardinal features include nondeforming joint pain and stiffness, a butterfly rash, photosensitivity, Raynaud’s phenomenon, seizures or psychoses, recurrent fever, lymphadenopathy, oral or nasopharyngeal ulcers, anorexia, and weight loss.
Urethral trauma
Hematuria may occur initially, possibly with blood at the urinary meatus, local pain, and penile or vulvar ecchymosis.
Vaginitis
When this infection spreads to the urinary tract, it may produce macroscopic hematuria. Related signs and symptoms may include urinary frequency and urgency, dysuria, nocturia, perineal pain, pruritus, and a malodorous vaginal discharge.
Vasculitis
Hematuria is usually microscopic in this disorder. Associated signs and symptoms include malaise, myalgia, polyarthralgia, fever, increased blood pressure, pallor and, occasionally, anuria. Other features, such as urticaria and purpura, may reflect the etiology of vasculitis.
Other causes
Diagnostic tests
Renal biopsy is the diagnostic test most often associated with hematuria. This sign may also result from biopsy or manipulative instrumentation of the urinary tract, as in cystoscopy.
Drugs
Drugs that commonly cause hematuria are anticoagulants, aspirin (toxicity), analgesics, cyclophosphamide, metyrosine, penicillin, rifampin, and thiabendazole.
Herb Alert
When taken with an anticoagulant, herbal medicines such as garlic and ginkgo biloba can cause excessive bleeding and hematuria.
Treatments
Any therapy that involves manipulative instrumentation of the urinary tract, such as transurethral prostatectomy, may cause microscopic or macroscopic hematuria. After a kidney transplant, a patient may experience hematuria with or without clots, which may require indwelling urinary catheter irrigation.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hematuria:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Urinary tract infection
❑ Nephrolithiasis
❑ Anticoagulation
❑ Long distance running
❑ Renal trauma
❑ Bladder cancer
❑ Renal cell cancer
❑ Transitional cell cancer
❑ Glomerulonephritis
❑ Interstitial cystitis
❑ Hemorrhagic cystitis
❑ Hemoglobinuria
❑ Endocarditis
❑ Polycystic kidney disease
❑ Renal artery embolism
❑ Renal vein thrombosis
❑ Endometrial implants
❑ Wegener granulomatosis
❑ Goodpasture syndrome
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Source: Field Guide to Bedside Diagnosis, 2007
Nephrotic syndrome:
Causes
(Handbook of Diseases)
About 75% of nephrotic syndrome cases result from primary (idiopathic) glomerulonephritis. Classifications include the following:
❑ With minimal change disease (lipid nephrosis or nil disease) — the main cause of nephrotic syndrome in children — the glomeruli appear normal by light microscopy. Some tubules may contain increased lipid deposits.
❑ Membraneous glomerulonephritis — the most common lesion in patients with adult idiopathic nephrotic syndrome — is characterized by uniform thickening of the glomerular basement membrane containing dense deposits. It can eventually progress to renal failure.
❑ Focal glomerulosclerosis can develop spontaneously at any age, follow kidney transplantation, or result from heroin abuse. Lesions initially affect the deeper glomeruli, causing hyaline sclerosis, with later involvement of the superficial glomeruli. These lesions generally cause slowly progressive deterioration in renal function. Remissions occur occasionally.
❑ With membranoproliferative glomerulonephritis, slowly progressive lesions develop in the subendothelial region of the basement membrane. These lesions may follow infection, particularly streptococcal infection. This disease occurs primarily in children and young adults.
Other causes of nephrotic syndrome include metabolic diseases such as diabetes mellitus; collagen-vascular disorders, such as systemic lupus erythematosus and polyarteritis nodosa; circulatory diseases, such as heart failure and sickle cell anemia; nephrotoxins, such as mercury, gold, and nonsteroidal anti-inflammatories; allergic reactions; infections, such as tuberculosis or hepatitis B; preeclampsia toxemia; hereditary nephritis; multiple myeloma; and other neoplastic diseases. These diseases increase glomerular protein permeability, leading to the increased urinary excretion of protein, especially albumin, and subsequent hypoalbuminemia.
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Source: Handbook of Diseases, 2003
Pyelonephritis, acute:
Causes
(Handbook of Diseases)
Acute pyelonephritis results from bacterial infection of the kidneys. Infecting bacteria usually are normal intestinal and fecal flora that grow readily in urine. The most common causative organism is Escherichia coli, but Proteus, Pseudomonas, Staphylococcus aureus, and Streptococcus faecalis may also cause such infections.
Typically, the infection spreads from the bladder to the ureters, then to the kidneys, as in vesicoureteral reflux. Vesicoureteral reflux may result from congenital weakness at the junction of the ureter and the bladder.
Bacteria refluxed to intrarenal tissues may create colonies of infection within 24 to 48 hours. Infection may also result from instrumentation (such as catheterization, cystoscopy, or urologic surgery), from a hematogenic infection (as in septicemia or endocarditis) or, possibly, from lymphatic infection.
Pyelonephritis may also result from an inability to empty the bladder (for example, in patients with neurogenic bladder), urinary stasis, or urinary obstruction due to tumors, strictures, or benign prostatic hyperplasia.
Pyelonephritis occurs more commonly in females, probably because of a shorter urethra and the proximity of the urinary meatus to the vagina and rectum (both of which allow bacteria to reach the bladder more easily) and a lack of the antibacterial prostatic secretions produced in the male.
Risk factors
Incidence increases with age and is higher in the following groups:
❑ sexually active women — increased risk of bacterial contamination from intercourse.
❑ pregnant women — about 5% develop asymptomatic bacteriuria; if untreated, about 40% develop pyelo-nephritis.
❑ diabetics — neurogenic bladder causes incomplete emptying and urinary stasis; glycosuria may support bacterial growth in the urine.
❑ people with other renal diseases — increased susceptibility resulting from compromised renal function.
CLINICAL TIP: Acute pyelo-nephritis is more likely to occur in patients who have undergone urinary tract manipulation — such as for the placement of a urinary catheter. Caution is advised in selecting patients for urinary catheter placement.
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Source: Handbook of Diseases, 2003
Glomerulo-nephritis, acute poststreptococcal:
Causes
(Handbook of Diseases)
APSGN results from the entrapment and collection of antigen-antibody complexes (produced as an immunologic mechanism in response to streptococci) in the glomerular capillary membranes, inducing inflammatory damage and impeding glomerular function.
Sometimes the immune complement further damages the glomerular membrane. The damaged and inflamed glomerulus loses the ability to be selectively permeable and allows red blood cells (RBCs) and proteins to filter through as the glomerular filtration rate (GFR) falls. Uremic poisoning may result.
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Source: Handbook of Diseases, 2003
Glomerulo-nephritis, chronic:
Causes
(Handbook of Diseases)
Common causes of chronic glomerulonephritis include primary renal disorders, such as membranoproliferative glomerulonephritis, membranous glomerulopathy, focal glomerulosclerosis, rapidly progressive glomerulonephritis and, less commonly, poststreptococcal glomerulonephritis.
Systemic disorders that may cause chronic glomerulonephritis include lupus erythematosus, Goodpasture’s syndrome, and diabetes mellitus.
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Source: Handbook of Diseases, 2003
Hematuria:
Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Appendicitis
About 15% of patients with appendicitis have either microscopic or macroscopic hematuria accompanied by bladder tenderness, dysuria, and urinary urgency. More typical findings include constant right-lower-quadrant pain (especially over McBurney’s point), nausea and vomiting, anorexia, abdominal rigidity, rebound tenderness, constipation, tachycardia, and low-grade fever.
Bladder cancer
A primary cause of gross hematuria in men, bladder cancer may also produce pain in the bladder, rectum, pelvis, flank, back, or leg. Other common features are nocturia, dysuria, urinary frequency and urgency, vomiting, diarrhea, and insomnia.
Bladder trauma
Gross hematuria is characteristic in traumatic rupture or perforation of the bladder. Typically, the hematuria is accompanied by lower abdominal pain and, occasionally, anuria despite a strong urge to void. The patient may also develop swelling of the scrotum, buttocks, or perineum and signs of shock, such as tachycardia and hypotension.
Calculi
Bladder and renal calculi produce hematuria, which may be associated with signs of urinary tract infection, such as dysuria and urinary frequency and urgency. Bladder calculi usually cause gross hematuria, referred pain to the lower back or penile or vulvar area and, in some patients, bladder distention.
Renal calculi may produce microscopic or gross hematuria. The cardinal symptom, though, is colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia when a calculus is passed. The pain may be excruciating at its peak. Other signs and symptoms may include nausea and vomiting, restlessness, fever, chills, abdominal distention and, possibly, decreased bowel sounds.
Coagulation disorders
Macroscopic hematuria is typically the first sign of hemorrhage in coagulation disorders, such as thrombocytopenia or disseminated intravascular coagulation. Among other features are epistaxis, purpura (petechiae and ecchymoses), and signs of GI bleeding.
Cystitis
Hematuria is a telling sign in all types of cystitis. Bacterial cystitis usually produces macroscopic hematuria with urinary urgency and frequency, dysuria, nocturia, and tenesmus. The patient complains of perineal and lumbar pain, suprapubic discomfort, and fatigue and occasionally has a low-grade fever.
More common in women, chronic interstitial cystitis occasionally causes grossly bloody hematuria. Associated features include urinary frequency, dysuria, nocturia, and tenesmus. Both microscopic and macroscopic hematuria may occur with tubercular cystitis, which may also cause urinary urgency and frequency, dysuria, tenesmus, flank pain, fatigue, and anorexia. Viral cystitis usually produces hematuria, urinary urgency and frequency, dysuria, nocturia, tenesmus, and fever.
Diverticulitis
When diverticulitis involves the bladder, it usually causes microscopic hematuria, urinary frequency and urgency, dysuria, and nocturia. Characteristic findings include left-lower-quadrant pain, abdominal tenderness, constipation or diarrhea and, at times, a palpable, firm, fixed, and tender abdominal mass. The patient may also develop mild nausea, flatulence, and a low-grade fever.
Endocarditis (subacute infective)
Occasionally, subacute infective endocarditis produces embolization, resulting in renal infarction and microscopic or gross hematuria. Among common related findings are constant fever, chills, night sweats, fatigue, pallor, anorexia, weight loss, polyarthralgia, petechiae, flank pain, severe back pain, stiff neck, cardiac murmurs, tachycardia, and splenomegaly.
Glomerulonephritis
Acute glomerulonephritis usually begins with gross hematuria that tapers off to microscopic hematuria and red cell casts, which may persist for months. It may also produce oliguria or anuria, proteinuria, mild fever, fatigue, flank and abdominal pain, generalized edema, increased blood pressure, nausea, vomiting, and signs of lung congestion, such as crackles and a productive cough.
Chronic glomerulonephritis usually causes microscopic hematuria accompanied by proteinuria, generalized edema, and increased blood pressure. Signs and symptoms of uremia may also occur in advanced disease.
Nephritis (interstitial)
Typically, this infection causes microscopic hematuria. However, some patients with acute interstitial nephritis may develop gross hematuria. Other findings are fever, maculopapular rash, and oliguria or anuria. In chronic interstitial nephritis, the patient has dilute — almost colorless — urine that may be accompanied by polyuria and increased blood pressure.
Nephropathy (obstructive)
Obstructive nephropathy may cause microscopic or macroscopic hematuria, but rarely is urine grossly bloody. The patient may report colicky flank and abdominal pain, CVA tenderness, and anuria or oliguria that alternates with polyuria.
Polycystic kidney disease
Polycystic kidney disease, a hereditary disorder, may cause recurrent microscopic or gross hematuria. Although usually asymptomatic before age 40, it may cause increased blood pressure, polyuria, dull flank pain, and signs of urinary tract infection, such as dysuria and urinary frequency and urgency. Later, the patient develops a swollen, tender abdomen and lumbar pain that’s aggravated by exertion and relieved by lying down. He may also have proteinuria and colicky abdominal pain from the ureteral passage of clots or stones.
Prostatic hyperplasia (benign)
About 20% of patients with enlarged prostates have macroscopic hematuria, usually when a significant obstruction is present. The hematuria is usually preceded by diminished urinary stream, tenesmus, and a feeling of incomplete voiding. It may be accompanied by urinary hesitancy, frequency, and incontinence; nocturia; perineal pain; and constipation. Inspection reveals a midline mass representing the distended bladder; rectal palpation reveals an enlarged prostate.
Prostatitis
Whether acute or chronic, prostatitis may cause macroscopic hematuria, usually at the end of urination. It may also produce urinary frequency and urgency and dysuria followed by visible bladder distention.
Acute prostatitis also produces fatigue, malaise, myalgia, polyarthralgia, fever with chills, nausea, vomiting, perineal and low back pain, and decreased libido. Rectal palpation reveals a tender, swollen, firm prostate.
Chronic prostatitis commonly follows an acute attack. It may cause persistent urethral discharge, dull perineal pain, ejaculatory pain, and decreased libido.
Pyelonephritis (acute)
Acute pyelonephritis typically produces microscopic or macroscopic hematuria that progresses to grossly bloody hematuria. After the infection resolves, microscopic hematuria may persist for a few months. Related signs and symptoms include persistent high fever, unilateral or bilateral flank pain, CVA tenderness, shaking chills, weakness, fatigue, dysuria, urinary frequency and urgency, nocturia, and tenesmus. The patient may also exhibit nausea, anorexia, vomiting, and signs of paralytic ileus, such as hypoactive or absent bowel sounds and abdominal distention.
Renal cancer
The classic triad of signs and symptoms of renal cancer includes grossly bloody hematuria; dull, aching flank pain; and a smooth, firm, palpable flank mass. Colicky pain may accompany the passage of clots. Other findings include fever, CVA tenderness, and increased blood pressure. In advanced disease, the patient may develop weight loss, nausea and vomiting, and leg edema with varicoceles.
Renal infarction
Typically, this disorder produces gross hematuria. The patient may complain of constant, severe flank and upper abdominal pain accompanied by CVA tenderness, anorexia, and nausea and vomiting. Other findings include oliguria or anuria, proteinuria, hypoactive bowel sounds and, a day or two after infarction, fever and increased blood pressure.
Renal papillary necrosis (acute)
Acute renal papillary necrosis usually produces grossly bloody hematuria, which may be accompanied by intense flank pain, CVA tenderness, abdominal rigidity and colicky pain, oliguria or anuria, pyuria, fever, chills, vomiting, and hypoactive bowel sounds. Arthralgia and hypertension are common.
Renal trauma
About 80% of patients with renal trauma have microscopic or gross hematuria. Accompanying signs and symptoms may include flank pain, a palpable flank mass, oliguria, hematoma or ecchymoses over the upper abdomen or flank, nausea and vomiting, and hypoactive bowel sounds. Severe trauma may precipitate signs of shock, such as tachycardia and hypotension.
Renal tuberculosis
Gross hematuria is often the first sign of renal tuberculosis. It may be accompanied by urinary frequency, dysuria, pyuria, tenesmus, colicky abdominal pain, lumbar pain, and proteinuria.
Renal vein thrombosis
Grossly bloody hematuria usually occurs in renal vein thrombosis. In abrupt venous obstruction, the patient experiences severe flank and lumbar pain as well as epigastric and CVA tenderness. Other features include fever, pallor, proteinuria, peripheral edema and, when the obstruction is bilateral, oliguria or anuria and other uremic signs. The kidneys are easily palpable. Gradual venous obstruction causes signs of nephrotic syndrome, proteinuria and, occasionally, peripheral edema.
Sickle cell anemia
In this hereditary disorder, gross hematuria may result from congestion of the renal papillae. Associated signs and symptoms of sickle cell anemia may include pallor, dehydration, chronic fatigue, polyarthralgia, leg ulcers, dyspnea, chest pain, impaired growth and development, hepatomegaly and, possibly, jaundice. Auscultation reveals tachycardia and systolic and diastolic murmurs.
Systemic lupus erythematosus
Gross hematuria and proteinuria may occur when systemic lupus erythematosus (SLE) involves the kidneys. Cardinal associated features include nondeforming joint pain and stiffness, a butterfly rash, photosensitivity, Raynaud’s phenomenon, seizures or psychoses, recurrent fever, lymphadenopathy, oral or nasopharyngeal ulcers, anorexia, and weight loss.
Urethral trauma
With urethral trauma, initial hematuria may occur, possibly with blood at the urinary meatus, local pain, and penile or vulvar ecchymoses.
Vaginitis
When vaginitis spreads to the urinary tract, it may produce macroscopic hematuria. Related signs and symptoms may include urinary frequency and urgency, dysuria, nocturia, perineal pain, pruritus, and a malodorous vaginal discharge.
Vasculitis
Hematuria is usually microscopic in vasculitis. Associated signs and symptoms include malaise, myalgia, polyarthralgia, fever, increased blood pressure, pallor and, occasionally, anuria. Other features, such as urticaria and purpura, may reflect the etiology of vasculitis.
Other causes
Diagnostic tests
Renal biopsy is the diagnostic test most often associated with hematuria. This sign may also result from biopsy or manipulative instrumentation of the urinary tract, as in cystoscopy.
Drugs
Drugs that commonly cause hematuria are anticoagulants, aspirin toxicity, analgesics, cyclophosphamide, metyrosine, phenylbutazone, penicillin, rifampin, and thiabendazole.
Treatments
Any therapy that involves manipulative instrumentation of the urinary tract, such as transurethral prostatectomy, may cause microscopic or macroscopic hematuria. Following a kidney transplant a patient may experience hematuria with or without clots, which may require indwelling urinary catheter irrigation.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hematuria:
Principal Causes of Hematuria
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
- Hematuriawithout proteinuria
- Glomerular disorders
- Acute postinfectious glomerulonephritis
- Immunoglobulin A nephropathy
- Henoch-Schönlein nephritis
- Alport syndrome
- Membranoproliferative glomerulonephritis
- Systemic lupus erythematosus
- Familial benign hematuria (thin basementmembrane nephropathy)
- Nonfamilial benign hematuria
- Nonglomerular disorders
- Urinarytract infection
- Trauma
- Exercise
- Hydronephrosis
- Renal vein thrombosis
- Hemoglobinopathies
- Idiopathic hypercalciuria
- Urolithiasis
- Polycystic kidney disease
- Renal tuberculosis
- Vascular malformations
- Foreign body in the urethra or bladder
- Neoplasm
- Bleeding disorders
- Drugs
- Hematuria with proteinuria
- Glomerulardisorders
- Acutepostinfectious glomerulonephritis
- Immunoglobulin A nephropathy
- Henoch-Schönlein nephritis
- Alport syndrome
- Membranoproliferative glomerulonephritis
- Systemic lupus erythematosus
- Membranous nephropathy
- Glomerulonephritis of chronic infection
- Idiopathic rapidly progressive glomerulonephritis
- Hemolytic-uremic syndrome
- Polyarteritis nodosa
- Antiglomerular basement membrane disease(Goodpasture disease)
- Focal segmental glomerulosclerosis
- Wegener granulomatosis
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Hematuria:
Medical causes
(Nursing: Interpreting Signs and Symptoms)
Bladder cancer.A primary cause of gross hematuria in men, bladder cancer may also produce pain in the bladder, rectum, pelvis, flank, back, or leg. Other common features are nocturia, dysuria, urinary frequency and urgency, vomiting, diarrhea, and insomnia.
Bladder trauma.Gross hematuria is characteristic in traumatic rupture or perforation of the bladder. Typically, hematuria is accompanied by lower abdominal pain and, occasionally, anuria despite a strong urge to void. The patient may also develop swelling of the scrotum, buttocks, or perineum and signs of shock, such as tachycardia and hypotension.
Calculi.Bladder and renal calculi produce hematuria, which may be associated with signs of a urinary tract infection (UTI), such as dysuria and urinary frequency and urgency. Bladder calculi usually cause gross hematuria, referred pain to the lower back or penile or vulvar area and, in some patients, bladder distention.
Renal calculi may produce microscopic or gross hematuria. The cardinal symptom, however, is colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia when a calculus is passed. The pain may be excruciating at its peak. Other signs and symptoms may include nausea and vomiting, restlessness, a fever, chills, abdominal distention and, possibly, decreased bowel sounds.
Coagulation disorders.Macroscopic hematuria is usually the first sign of hemorrhage in coagulation disorders, such as thrombocytopenia or disseminated intravascular coagulation. Other features include epistaxis, purpura (petechiae and ecchymoses), and signs of GI bleeding.
Cortical necrosis (acute).Accompanying gross hematuria in acute cortical necrosis are intense flank pain, anuria, leukocytosis, and a fever.
Cystitis.Hematuria is a telling sign in all types of cystitis. Bacterial cystitis usually produces macroscopic hematuria with urinary urgency and frequency, dysuria, nocturia, and tenesmus. The patient complains of perineal and lumbar pain, suprapubic discomfort, and fatigue and occasionally has a low-grade fever.
More common in women, chronic interstitial cystitis occasionally causes grossly bloody hematuria. Associated features include urinary frequency, dysuria, nocturia, and tenesmus. Microscopic and macroscopic hematuria may occur with tubercular cystitis, which may also cause urinary urgency and frequency, dysuria, tenesmus, flank pain, fatigue, and anorexia. Viral cystitis usually produces hematuria, urinary urgency and frequency, dysuria, nocturia, tenesmus, and a fever.
Diverticulitis.When diverticulitis involves the bladder, it usually causes microscopic hematuria, urinary frequency and urgency, dysuria, and nocturia. Characteristic findings include left lower quadrant pain, abdominal tenderness, constipation or diarrhea and, at times, a palpable, firm, fixed, and tender abdominal mass. The patient may also develop mild nausea, flatulence, and a low-grade fever.
Glomerulonephritis.Acute glomerulonephritis usually begins with gross hematuria that tapers off to microscopic hematuria and red cell casts, which may persist for months. It may also produce oliguria or anuria, proteinuria, a mild fever, fatigue, flank and abdominal pain, generalized edema, increased blood pressure, nausea, vomiting, and signs of lung congestion, such as crackles and a productive cough.
Chronic glomerulonephritis usually causes microscopic hematuria accompanied by proteinuria, generalized edema, and increased blood pressure. Signs and symptoms of uremia may also occur in advanced disease.
Nephritis (interstitial).Typically, nephritis causes microscopic hematuria. However, the patient with acute interstitial nephritis may develop gross hematuria. Other findings are a fever, a maculopapular rash, and oliguria or anuria. In chronic interstitial nephritis, the patient has dilute—almost colorless—urine that may be accompanied by polyuria and increased blood pressure.
Nephropathy (obstructive).Obstructive nephropathy may cause microscopic or macroscopic hematuria, but urine is rarely grossly bloody. The patient may report colicky flank and abdominal pain, CVA tenderness, and anuria or oliguria that alternates with polyuria.
Polycystic kidney disease.Polycystic kidney disease is a hereditary disorder that may cause recurrent microscopic or gross hematuria. Although it commonly produces no symptoms before age 40, it may cause increased blood pressure, polyuria, dull flank pain, and signs of a UTI, such as dysuria and urinary frequency and urgency. Later, the patient develops a swollen, tender abdomen and lumbar pain that's aggravated by exertion and relieved by lying down. He may also have proteinuria and colicky abdominal pain from the ureteral passage of clots or calculi.
Prostatitis.Whether acute or chronic, prostatitis may cause macroscopic hematuria, usually at the end of urination. It may also produce urinary frequency and urgency and dysuria followed by visible bladder distention.
Acute prostatitis also produces fatigue, malaise, myalgia, polyarthralgia, a fever with chills, nausea, vomiting, perineal and low back pain, and a decreased libido. Rectal palpation reveals a tender, swollen, boggy, firm prostate.
Chronic prostatitis commonly follows an acute attack. It may cause persistent urethral discharge, dull perineal pain, ejaculatory pain, and a decreased libido.
Pyelonephritis (acute).Acute pyelonephritis typically produces microscopic or macroscopic hematuria that progresses to grossly bloody hematuria. After the infection resolves, microscopic hematuria may persist for a few months. Related signs and symptoms include a persistent high fever, unilateral or bilateral flank pain, CVA tenderness, shaking chills, weakness, fatigue, dysuria, urinary frequency and urgency, nocturia, and tenesmus. The patient may also exhibit nausea, anorexia, vomiting, and signs of paralytic ileus, such as hypoactive or absent bowel sounds and abdominal distention.
Renal cancer.The classic triad of signs and symptoms of renal cancer includes grossly bloody hematuria; dull, aching flank pain; and a smooth, firm, palpable flank mass. Colicky pain may accompany the passage of clots. Other findings include a fever, CVA tenderness, and increased blood pressure. In advanced disease, the patient may develop weight loss, nausea and vomiting, and leg edema with varicoceles.
Renal infarction.Typically, renal infarction produces gross hematuria. The patient may complain of constant, severe flank and upper abdominal pain accompanied by CVA tenderness, anorexia, and nausea and vomiting. Other findings include oliguria or anuria, proteinuria, hypoactive bowel sounds and, a day or two after infarction, a fever and increased blood pressure.
Renal papillary necrosis (acute).Acute renal papillary necrosis usually produces grossly bloody hematuria, which may be accompanied by intense flank pain, CVA tenderness, abdominal rigidity and colicky pain, oliguria or anuria, pyuria, fever, chills, vomiting, and hypoactive bowel sounds. Arthralgia and hypertension are common.
Renal trauma.About 80% of patients with renal trauma have microscopic or gross hematuria. Accompanying signs and symptoms may include flank pain, a palpable flank mass, oliguria, hematoma or ecchymoses over the upper abdomen or flank, nausea and vomiting, and hypoactive bowel sounds. Severe trauma may precipitate signs of shock, such as tachycardia and hypotension.
Renal tuberculosis.Gross hematuria is commonly the first sign of renal tuberculosis. It may be accompanied by urinary frequency, dysuria, pyuria, tenesmus, colicky abdominal pain, lumbar pain, and proteinuria.
Renal vein thrombosis.Grossly bloody hematuria usually occurs in renal vein thrombosis. In abrupt venous obstruction, the patient experiences severe flank and lumbar pain as well as epigastric and CVA tenderness. Other features include a fever, pallor, proteinuria, peripheral edema and, when the obstruction is bilateral, oliguria or anuria and other uremic signs. The kidneys are easily palpable. Gradual venous obstruction causes signs of nephrotic syndrome, proteinuria and, occasionally, peripheral edema.
Schistosomiasis.Schistosomiasis usually causes intermittent hematuria at the end of urination. It may be accompanied by dysuria, colicky renal and bladder pain, and palpable lower abdominal masses.
Sickle cell anemia.Sickle cell anemia is a hereditary disorder in which gross hematuria may result from congestion of the renal papillae. Associated signs and symptoms may include pallor, dehydration, chronic fatigue, polyarthralgia, leg ulcers, dyspnea, chest pain, impaired growth and development, hepatomegaly and, possibly, jaundice. Auscultation reveals tachycardia and systolic and diastolic murmurs.
Systemic lupus erythematosus (SLE).Gross hematuria and proteinuria may occur when SLE involves the kidneys. Cardinal associated features include nondeforming joint pain and stiffness, a butterfly rash, photosensitivity, Raynaud's phenomenon, seizures or psychoses, a recurrent fever, lymphadenopathy, oral or nasopharyngeal ulcers, anorexia, and weight loss.
Urethral trauma.Initial hematuria may occur, possibly with blood at the urinary meatus, local pain, and penile or vulvar ecchymoses.
Vasculitis.Hematuria is usually microscopic in vasculitis. Associated signs and symptoms include malaise, myalgia, polyarthralgia, a fever, increased blood pressure, pallor and, occasionally, anuria. Other features, such as urticaria and purpura, may reflect the etiology of vasculitis.
Other causes
Diagnostic tests.Renal biopsy is the diagnostic test most commonly associated with hematuria. This sign may also result from biopsy or manipulative instrumentation of the urinary tract such as in cystoscopy.
Drugs.Drugs that commonly cause hematuria are anticoagulants, aspirin (toxicity), analgesics, cyclophosphamide, metyrosine, phenylbutazone, oxyphenbutazone, penicillin, rifampin, and thiabendazole.
Treatments.Any therapy that involves manipulative instrumentation of the urinary tract, such as transurethral prostatectomy, may cause microscopic or macroscopic hematuria. Following a kidney transplant, a patient may experience hematuria with or without clots, which may require indwelling urinary catheter irrigation.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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