Diagnosis of Oliguria
Oliguria Diagnosis: Book Excerpts
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HEMATURIA:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there abdominal pain? The presence of abdominal pain with hematuria should first suggest renal calculus, but other causes, such as renal embolism, renal contusion, or laceration, must be considered.
- Is there dysuria or frequency of micturition associated with the hematuria? The presence of dysuria and frequency with the hematuria should suggest a bladder stone, prostatic disease, or a UTI.
- Is there fever? The presence of fever with the hematuria would suggest pyelonephritis.
- Is there a flank mass? The presence of bilateral flank masses with hematuria should suggest polycystic kidneys and hydronephrosis, whereas a unilateral flank mass would suggest a hypernephroma or unilateral hydronephrosis. A solitary cyst or renal vein thrombosis may also present with a flank mass and hematuria.
- Is there hypertension? The presence of hypertension with the hematuria suggests glomerulonephritis, polycystic kidneys, and collagen diseases.
- Are there other systemic signs and symptoms? If there are other systemic signs and symptoms, one should be looking for collagen disease, coagulation disorders, leukemia, and sickle cell anemia. When there is no hypertension or other signs and symptoms of systemic diseases, one should be looking for a benign or malignant tumor of the bladder, tuberculosis, or parasitic infection.
DIAGNOSTIC WORKUP
The workup begins with a urinalysis and microscopic examination of the urinary sediment. The physician can easily do this in his office. If there is proteinuria, granular cast, and red cell cast, glomerulonephritis or collagen disease should be suspected. A culture and sensitivity and colony count should be done if a UTI is suspected. A three-glass test may be done. If there is blood in the initial specimen, the cause is most likely in the urethra or male genitalia. If it is in the final specimen, the cause is most likely a bladder lesion. Phase-contrast microscopy may also be helpful in identifying hematuria from a glomerular lesion. If this is negative, an anaerobic culture should be done also and then an AFB smear and culture and guinea pig inoculation to rule out tuberculosis. An intravenous pyelogram will also usually have to be done. A CBC, sedimentation rate, chemistry panel, coagulation profile, and ANA test will help rule out blood dyscrasias, collagen diseases, and other systemic diseases. Ultrasonography may help diagnose a renal cyst.
If the above are not revealing, referral to a urologist is indicated. He will probably do a cystoscopy and retrograde pyelography. He may also want to order a CT scan of the abdomen and pelvis and a renal biopsy. Renal angiography and aortography may be necessary to evaluate renovascular hypertension and renal embolism.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
ANURIA OR OLIGURIA:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Has the patient been on any drugs? Sulfonamides are notorious for causing renal failure, but one must also consider amphotericin B, gold compounds that might be administered in arthritis, and lead and other drugs or heavy metals.
- What is the blood pressure? If there is hypertension and anuria, one should consider acute or chronic glomerulonephritis, polycystic kidneys, and acute tubular necrosis. If there is a low blood pressure, one should consider prerenal causes of anuria such as dehydration, blood loss, the acute abdomen, and other causes of shock.
- Is there cardiomegaly or chest pain? If there is an enlarged heart, one should consider congestive heart failure. If there is chest pain, one should consider myocardial infarction or pulmonary infarction. If there is chest or abdominal pain with hypertension, then one should consider dissecting aneurysm.
- Is there enlargement of the kidneys? Enlargement of both kidneys should suggest bilateral hydronephrosis or polycystic kidneys. Unilateral enlargement of the kidneys is not usually associated with anuria.
- Is there bladder enlargement? Enlarged bladder would make one think of bladder neck obstructions due to prostatic hypertrophy or carcinoma or a urethral stricture. Occasionally, what is thought to be an enlarged bladder is actually a pelvic mass that is obstructing the ureter.
- Is there hematuria? Hematuria would suggest glomerulonephritis, acute tubular necrosis, intravascular hemolysis, and nephrolithiasis.
- What has been the patient's recent intake of fluid? Dehydration is a frequent cause of oliguria and anuria.
DIAGNOSTIC WORKUP
The first thing to determine is whether the patient really has anuria or oliguria. A Foley catheter should be passed and attached to drainage to determine the urine output. If there is obstructive uropathy due to bladder neck obstruction, obviously this will determine the diagnosis, as there will be a large volume of urine and it should be taken off gradually. Then studies of obstructive uropathy can be done, including cystoscopy and retrograde pyelography. If the obstructive uropathy is due to obstruction of the ureter, renal ultrasonography can be reliable in detecting the dilated calyces or dilated ureter.
If the patient presents with anuria and hypotension, the most important thing is to reestablish the blood pressure. If the anuria does not cease at this point, high-dose furosemide or a mannitol infusion can be started. Meanwhile, a CBC, chemistry panel, urinalysis, spot urine sodium, serum protein electrophoresis, an ANA assay, an EKG, and chest x-ray should be done. A flat plate of the abdomen should give an idea of the kidney size. The clinician should examine the urinary sediment himself, and this will identify cases of acute glomerulonephritis, lupus erythematosus, and acute tubular necrosis with considerable accuracy. The blood urea nitrogen (BUN) and creatinine ratio are helpful in distinguishing pre-renal from renal azotemia.
If intravascular hemolysis is suspected, serum haptoglobins and serum hemoglobin should be done. Eosinophilia of the blood or urine will be found in drug-induced nephritis. Renal angiography and aortography should be done in cases of suspected dissecting aneurysm or bilateral renal artery stenosis. Abdominal ultrasound will also be helpful in diagnosing polycystic kidneys and pelvic masses that may be obstructing the ureter. A CT scan may be necessary as well.
In difficult cases, a renal biopsy may be necessary to diagnose the various collagen diseases and the various forms of glomerulonephritis. Referral to a nephrologist would be best at this point.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hematuria:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
Transient hematuria
–Urinary tract infection/pyelonephritis
–Nephrolithiasis (kidney or bladder stones)
–Exercise
–Trauma, instrumentation, catheterization, or foreign bodies
–Endometriosis
–Transient unexplained
–Henoch-Schönlein purpura/HUS
–Coagulopathy and excess anticoagulation
–Prostatitis, epididymitis
Persistent hematuria
–Sickle cell anemia
–Cancer (prostate, bladder, kidney)
–Benign prostatic hypertrophy
–Polycystic kidney disease
–Intrinsic glomerular disease Other causes of red or brown urine (pseudohematuria)
–Beeturia (14% population are susceptible after eating beets): Due to excretion of betalaine, a reddish pigment
–Myoglobinuria: Rapidly filtered and excreted; source is usually due to rhabdomyolysis; look for increased elevation of plasma CPK levels
–Hemoglobinuria: Occurs when the filtered load of unbound dimer exceeds resorptive capacity of the proximal tubules, generally at serum levels >100–150 mg/dL
Urethral carbuncle
Urethritis (e.g., Chlamydia)
Porphyria
Phenazopyridine (bladder analgesic): Produces an orange color in urine
Postinfectious glomerulonephropathy
Hereditary (Alport's syndrome)
IgA nephropathy (Berger's disease): Often see gross hematuria without positive family history of disease
Loin pain hematuria syndrome
Thin basement membrane disease (benign familial hematuria): Usually see microscopic hematuria; gross hematuria or renal failure is rare
Hypercalciuria or hyperuricuria
Arteriovenous malformation
Fistula
Others include food dyes, phenolphthalein, rifampin, and porphyrins
Excessive anticoagulation
Trauma
Workup and Diagnosis
-
History and physical examination
-
Urinalysis in all patients (consider catheterization to
distinguish vaginal bleeding from other sources)
–Blood clots occur with extraglomerular sources
–Glomerular source of bleeding results in RBC casts, large
amounts of protein, dysmorphic RBCs
–UTI results in pyuria, nitrates, leukocyte esterase
-
Initial labs include BUN/creatinine, electrolytes, calcium, uric acid, CBC, and PT/PTT
-
Centrifuge urine sample: Red sediment only suggests hematuria (RBCs in the urine); heme-negative red supernatant suggests hemoglobinuria; heme-positive clear supernatant suggests myoglobinuria
-
Three-tube test: #1, collect first few mL of urine; #2, midstream; #3, last few mL
–Hematuria in #1 suggests urethral lesion; in #3, bladder trigone lesion; equally in all three, diffuse lesion
-
IVP (contraindicated in dye allergy), renal ultrasound, or spiral CT to evaluate for stones and renal masses
-
Urine cytology and cystoscopy for patients at risk for bladder cancer (e.g., smoking, cyclophosphamide)
-
Consider C3 level, ANA, ANCA, Anti-GBM, ASO, cryoglobulins, and hepatitis C antibodies
-
Renal biopsy if persistent hematuria with negative workup and evidence of progression (increasing proteinuria, creatinine, and blood pressure)
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Source: In a Page: Signs and Symptoms, 2004
Hematuria:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Transient (fever, dehydration, exercise)
-
Urinary tract infection
–Most common cause of gross hematuria
-
Hypercalciuria (common)
- Primary glomerulonephritis (GN)
–Acute poststreptococcal GN: Gross hematuria ±hypertension, oliguria; 5 days to several weeks after Group A strep pharyngitis or pyoderma; can also occur after other infections
–IgA nephropathy (Berger disease): recurrent gross hematuria occurs at or near onset of a URI
–Membranoproliferative GN
-
GN associated with systemic disease
–HSP
–SLE
–Other vasculitis (rare) e.g.,Wegener
-
Other glomerular disease
–Benign familial hematuria
–Alport syndrome: Usually X linked, high-
frequency deafness, progression to renal failure
–Glomerular disease (e.g., FSGS) usually presents as nephrotic syndrome
-
Tubulointerstitial disease
–Polycystic kidney disease, interstitial
nephritis, papillary necrosis, ATN
-
Urinary pelvic junction obstruction
-
Urolithiasis/nephrolithiasis
–Painless in up to 50% of children
-
Urethrorrhagia
–Recurrent gross hematuria (spotting on the
underwear)
–Most common in peripubertal males
-
Malignancies (e.g., Wilms tumor)
-
Vascular (e.g., renal vein thrombosis)
-
Trauma
-
Non-urinary tract blood
–Menses, perineal irritation, pinworms, masturbation, STDs, sexual abuse
-
Munchausen/Munchausen by proxy (rare)
Workup and Diagnosis
-
History
–Antecedent illness (including timing)
–Prior episodes, medication/food exposure
–Quality of gross hematuria (if present): Color, terminal vs present throughout stream, clots
–Symptoms: Fever, flank pain, dysuria, rash, hemoptysis, breathing difficulty, joint complaints
–Family history: Kidney stones, kidney disease, deafness (Alport)
-
Physical exam
–Blood pressure, growth parameters, skin or pharyngeal lesions, cardiac gallop, rales, edema, CVAT, genitourinary exam (external)
- Labs/studies
–U/A (dipstick and microscopy), urine culture
–Dipstick negative =foods, medications
–Dipstick positive, no RBCs =myoglobin, hemoglobin
–Dipstick positive, with RBCs =hematuria
–Macroscopic or microscopic with symptoms (e.g., HTN): Serum chemistries, CBC, ASO, C3, ANA, sickle prep, spot urine calcium/creatinine, STD screen (if sexually active), renal/bladder ultrasound, consider noncontrast helical CT if kidney stones suspected
–Microscopic hematuria, no symptoms: Repeat U/A two times, 1 week apart; if persists, check serum chemistries, urine culture, sickle prep, spot urine calcium/creatinine and U/As of parents/siblings
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Source: In A Page: Pediatric Signs and Symptoms, 2007
HEMATURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical picture will point to the diagnosis in many cases. If there is a history of abdominal trauma, a contusion or laceration of the kidney or bladder should be suspected. Massive trauma anywhere prompts a tentative diagnosis of crush syndrome. Purpura or bleeding from other sites suggests a coagulation disorder. Severe colicky pain in the abdomen suggests kidney stone. A long history of hypertension tension suggests polycystic kidneys, renal artery stenosis, or glomerulonephritis. A history of fever and rheumatic valvular disease suggests SBE with renal embolism. Painless hematuria in an otherwise healthy looking adult suggests neoplasm, whereas painful hematuria with frequency and dysuria suggests cystitis. Hematuria and a flank mass would make a neoplasm or polycystic kidney likely.
The initial workup should include a CBC, urinalysis, urine culture, chemistry panel, flat plate of the abdomen to assess the presence of stones and kidney size, and personal examination of the urinary sediment. If a renal calculus is suspected, an IVP is ordered immediately and a urologist consulted. A three-glass test will help localized the site of the bleeding. If there is blood in the initial specimen only, the urethra is probably the site of bleeding. If the blood is primarily in the final specimen, the bladder is most likely the site of bleeding. Equal blood discoloration in all specimens points to a renal lesion.
If renal tuberculosis is suspected an AFB smear and culture is done. If collagen disease is suspected an ANA analysis and anti–double strand DNA antibody titer is ordered. If a renal carcinoma is suspected, a CT scan of the abdomen is probably the best study to order but the advice of the urologist ought to be sought. Ultrasonography is useful in differentiating cysts from tumors. If a bladder neoplasm is suspected, cystoscopy will be done. If renal artery embolism or thrombosis is suspected, renal angiography may need to be done to clearly make the diagnosis.
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Source: Differential Diagnosis in Primary Care, 2007
ANURIA AND OLIGURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical picture will be helpful in determining the cause of anuria. In cases of prerenal azotemia, there will be decreased skin turgor and orthostatic hypotension if the cause is volume depletion. If the cause is CHF, there will be jugular vein distention, hepatomegaly, and pedal edema. Patients with postrenal azotemia may have an enlarged prostate, a distended bladder, and other signs of obstructive uropathy. Patients with renal azotemia may have bilateral flank masses (polycystic kidney), hypertension, peripheral emboli (embolic glomerulonephritis), or a rash (collagen disease, interstitial nephritis).
The initial workup includes a CBC; urinalysis; urine culture and sensitivity; personal examination of the urine for casts, and so forth; chemistry panel; spot urine sodium; serum and urine osmolality; flat plate of the abdomen for kidney size; chest x-ray; and ECG. The bladder is catheterized for residual urine and if this is significant, postrenal azotemia is likely and a urologist is consulted. He will most likely do a cystoscopy and retrograde pyelography once the patient’s condition is stabilized. Ultrasonography can be used to determine if there is significant residual urine also.
The laboratory studies will determine whether there is prerenal or renal azotemia. If the sodium concentration in the spot urine is less than 10 meq/L, prerenal azotemia is likely. Also, in prerenal Azotemia, the BUN: creatinine ratio is 20:1 or greater and the urine osmolality is 450 mOsm per kilogram of water or greater. The urine sediment will show granular and red cell casts in most cases of renal azotemia, and the BUN:creatinine ratio will be 10:1 or less.
Further workup will depend on what the presumptive diagnosis is. If volume depletion is the cause, intravenous saline and plasma volume expanders are given while carefully monitoring the urine output. If this is ineffective, furosemide and a mannitol drip can be utilized to reestablish urine output. If these measures are ineffective, the patient obviously has a renal cause for his/her anuria and a urologist should be consulted.
Renal causes can be differentiated by further workup. If intravascular hemolysis is suspected, serum haptoglobins should be ordered. If dissecting aneurysm or bilateral renal artery stenosis is suspected, aortography and angiography would be done. If polycystic kidney disease is suspected, ultrasonography or CT scan of the abdomen may be done. Eosinophilia of the blood or urine will be found in drug-induced nephritis. If a collagen disease is suspected, one should order an ANA, double-stranded DNA (dsDNA) antibody titer or lupus erythematosus (LE) cell prep. A renal biopsy may also be necessary in these disorders and many others.
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Source: Differential Diagnosis in Primary Care, 2007
Bladder distention:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If distention isn't severe, begin by reviewing the patient's voiding patterns. Find out the time and amount of the patient's last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva's or Credé's maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient's history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs.
Take the patient's vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can't be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Hematuria:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
After detecting hematuria, take a pertinent health history. If hematuria is macroscopic, ask the patient when he first noticed blood in his urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or end of urination? Has it occurred before? Is the patient passing clots? To rule out artifactitious hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if there’s pain or burning with hematuria episodes.
Ask about recent abdominal or flank trauma. Has the patient been exercising strenuously? Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history, noting anticoagulants or aspirin.
Begin the physical examination by palpating and percussing the abdomen and flanks. Next, percuss the costovertebral angle (CVA) to elicit tenderness. Check the urinary meatus for bleeding or other abnormalities. Using a chemical reagent strip, test a urine specimen for protein. A vaginal or digital rectal examination may be necessary.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Oliguria:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).
Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.
Begin the physical examination by taking the patient’s vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.
Obtain a urine sample and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Anuria:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Take the patient’s vital signs and obtain a complete history. First, ask about changes in his voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting especially previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about abdominal, renal, or urinary tract surgery.
Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Bladder distention:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If distention isn’t severe, begin by reviewing the patient’s voiding patterns. Find out the time and amount of the patient’s last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva’s or Credé’s maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient’s history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Ask about his drug history, including his use of over-the-counter drugs.
Take the patient’s vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can’t be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hematuria:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
After detecting hematuria, take a pertinent health history. If hematuria is macroscopic, ask the patient when he first noticed blood in his urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or end of urination? Has it occurred before? Is the patient passing any clots? To rule out artifactual hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if pain or burning accompanies the episodes of hematuria.
Ask about recent abdominal or flank trauma. Has the patient been exercising strenuously? Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history, noting the use of anticoagulants or aspirin.
Begin the physical examination by palpating and percussing the abdomen and flanks. Next, percuss the costovertebral angle (CVA) to elicit tenderness. Check the urinary meatus for bleeding or other abnormalities. Using a chemical reagent strip, test a urine specimen for protein. A vaginal or digital rectal examination may be necessary.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Oliguria:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).
Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss, as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.
Begin the physical examination by taking the patient’s vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds, and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.
Obtain a urine sample and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Anuria:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Take the patient’s vital signs and obtain a complete history. First ask about any changes in his voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting especially previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about any abdominal, renal, or urinary tract surgery.
Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys both anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hematuria:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A thorough history is of utmost importance!
A. General aspects
1. Type of hematuria (macro/gross or microscopic).
2. Relationship to urination or timing of hematuria. The three-container method will help to separate the micturition into three portions with an initial, middle, and final portion.
Predominantly, initial hematuria results from anterior urethral disease; final hematuria results from disease of the bladder neck or posterior urethra; and hematuria throughout the stream suggests a disease site higher in the bladder, ureter, or kidney.
3. Urine color. Color can be affected by the following: Phenazopyridine (orange); nitrofurantoin (brown); rifampin (yellow-orange); l-dopa, methyldopa, and metronidazole (reddish-brown); phenolphthalein in laxatives, red beet and rhubarb consumption, food coloring, and vegetable dyes (red).
4. Clots, especially wormlike clots, suggest a location above the bladder neck.
5. Associated symptoms (e.g., recent sore throat, fever, chills, and flulike symptoms) may be the first sign of IgA nephropathy or postinfectious glomerulonephritis. Urinary frequency, dysuria, fever, chills, and urgency point to an infectious process. Diminished urine flow and abdominal pain or flank pain radiating into the groin can indicate the presence of urinary tract obstruction (Chapter 10.5). Vaginal discharge or bowel movement changes may hint at a nonurinary tract cause such as a foreign body (especially in children). A rash, joint pain, photosensitivity, flulike symptoms, and Raynaud’s phenomenon point to a collagen vascular disease.
B. Past medical history should lead to a suspicion of parasites (e.g., Schistosoma heamatobium) if the patient has traveled to endemic areas; of bladder tumor if there was exposure to chemical carcinogens (e.g., aniline dyes), or tobacco smoke. Other causes of hematuria detected in the history include drug ingestion and anticoagulation, and medical problems such as prostatic hypertrophy, diabetes mellitus (nephrosclerosis), analgesic medication abuse (renal papillary necrosis), nephrolithiasis, trauma (including vigorous masturbation), chemotherapy exposure with cyclophosphamide (chemical cystitis), antibiotic use (interstitial nephritis), previous urinary tract malignancies suggesting recurrence, and sickle cell disease (papillary necrosis).
C. Family history. Delineate any family history of polycystic kidney disease, sickle cell trait and disease, nephrolithiasis, various glomerular diseases, tuberculosis, and benign familial hematuria. The combination of renal failure, deafness, and hematuria suggests Alport’s hereditary nephritis.
Physical examination
should focus on signs of systemic disease (fever, rash, lymphadenopathy, joint swelling, and abdominal or pelvic mass), and underlying medical or renal disease (hypertension, edema). Multiple telangiectasias and mucous membrane lesions indicate hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease). An abdominal mass in children requires exclusion of Wilms tumor.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Oliguria and Anuria:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Pertinent present history. A patient may complain of decreased urine output in some clinical situations. More often, however, the clinical situation and pertinent history should lead to an evaluation of the presence of oliguria or anuria.
1. Are there symptoms of illness or trauma leading to hypotension?
a. Hypovolemia (e.g., hemorrhage, diuretic overuse, gastrointestinal fluid loss, skin fluid loss owing to burns or heat exposure, third spacing, secondary to burns, peritonitis, pancreatitis, or trauma)?
b. Decreased cardiac output (e.g., congestive heart failure, myocardial infarction, pericardial tamponade, or acute pulmonary embolus)?
c. Peripheral vasodilatation (e.g., septic shock, anaphylactic shock)?
2. Are there symptoms of vascular disease? Consider bilateral renal vascular obstruction due to severe renal artery stenosis, thrombosis, or embolism.
3. Is there any history consistent with renal parenchymal injury [e.g., recent radiocontrast agent, nephrotoxin exposure such as ethylene glycol, nonsteroidal antiinflammatory drug overdose, acute nephritis, acute vasculitis, pyelonephritis (in the elderly), papillary necrosis (in diabetic patients), or prolonged hypotension with hypoperfusion of the kidney]?
4. Is there any history consistent with urinary tract obstruction?
a. Bladder neck obstruction (e.g., benign prostatic hypertrophy, prostate cancer, bladder cancer, or functional obstruction due to drug side effects)?
b. Obstruction of the urethra or bilateral ureters—internally (2° blood clots, stones, sulfonamide or uric acid crystals, pyogenic debris, necrotizing papillitis or edema), or externally (2° tumor, periureteral fibrosis, accidental ureteral ligation during pelvic surgery, ascites, pregnancy, pelvic abscess, or hematoma).
5. Medication use must be considered—diuretics, antihypertensives, anticholinergics, aminogycosides, amphotericin B, or chemotherapeutic drugs.
B. Other pertinent past history. Is there a history of cancer, recent surgery, kidney stones, neurologic disorder, vascular disease, chronic liver disease (hepatorenal syndrome), or kidney transplant?
Physical examination
A. Focused physical examination (PE). This should include vital signs (notably blood pressure, pulse, and temperature). Orthostatic blood pressure and pulse may be necessary. Signs of hypovolemia, hypotension, and dehydration should be noted—skin turgor and color, mucous membranes, capillary refill, warmth of extremities.
B. Additional PE. Depending on the history (e.g., skin rash, cardiac examination, bruits over kidneys) palpate for a distended bladder; if a cancer or outlet obstruction is suspected, perform a rectal or pelvic examination.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
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
Diagnostic Approach
A reasonable cutoff for discriminating benign from serious causes of hematuria is 10 RBCs/HPF. The urine dipstick detects as few as 1 to 2 RBCs/HPF. Analysis of the urine sediment is crucial. White cells and bacteria are indicative of cystitis whereas white cell casts are seen in pyelonephritis. Red cell casts and dipstick proteinuria indicate glomerulonephritis. Red cells from a glomerular source tend to be distorted. A positive dipstick for hemoglobin but no RBCs in the urinalysis suggests the presence of myoglobin or free hemoglobin derived from intravascular hemolysis. Menstrual blood contamination needs to be considered in the differential of microscopic hematuria.
Initial hematuria suggests a urethral source; terminal hematuria, the prostatic urethra, trigone, or base; and total hematuria, the kidney, ureter, or bladder. Massive hematuria is usually associated with bladder neoplasm, benign prostatic hypertrophy, or trauma. Bright red urine suggests a lower urinary source. Passage of bulky disc-like or fragmented clots implies the bladder as source, long shoestring clots suggest a ureteral origin, and pyramidal clots are from the renal pelvis. Glomerular sources virtually never produce clots (due to the presence of tissue plasminogen activators in the glomeruli and tubules). With a presentation of painless total hematuria, a urinary tract cancer is found in 20%.
Flank pain associated with hematuria may result from the passage of stones or clots. Hypertension suggests renal disease. Rash, fever, arthralgia/arthritis, or hemoptysis suggests a connective tissue disease or vasculitis. Beets, blackberries, and rhubarb, as well as pyridium, rifampin, phenothiazines, and anthracyclines, can produce red urine without blood.
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Source: Field Guide to Bedside Diagnosis, 2007
Anuria/Oliguria:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Acute tubular necrosis
❑ Prerenal azotemia
❑ Tubular toxins
❑ Bladder outlet obstruction
❑ Bilateral renal artery occlusion
❑ Nephrosclerosis
❑ Acute glomerulonephritis
❑ Interstitial nephritis
❑ Renal artery thrombosis
❑ Renal vein thrombosis
❑ Ureteral calculus with a solitary kidney
❑ Pelvic tumor
❑ Retroperitoneal fibrosis
❑ Infiltrative renal disease
❑ Vasculitis
❑ Rhabdomyolysis
Diagnostic Approach
Distinguish anuria from urinary retention. Nonobstructive anuria is accompanied by symptoms of uremia with vomiting, drowsiness, muscle twitch, headache, and asterixis. Urinary retention causes suprapubic pain, constant urgency, and a palpable bladder with dullness to percussion in the suprapubic region.
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Source: Field Guide to Bedside Diagnosis, 2007
Bladder distention:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Ask the patient about voiding patterns, the time and amount of the last voiding, and the amount of fluid he consumed since the last voiding. Does he have a history of difficulty when urinating? Ask whether Valsalva’s maneuver or Credé’s maneuver is required to initiate urination. Does he experience an urgent need to urinate? Does the urge to urinate arise without warning? Is urination painful or irritating? Ask about the force and continuity of the urine stream and whether the bladder is empty after voiding.
Assess the patient’s history for the presence of a urinary tract obstruction or infections, venereal disease, lower abdominal or urinary tract trauma, systemic or neurologic disorders, and neurologic, intestinal, or pelvic surgery. Note medication history, including the use of over-the-counter or recreational drugs.
Physical examination
Take the patient’s vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can’t be palpated through the abdominal wall.) Inspect the urethral meatus. Document the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Anuria:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Obtain a complete history, including changes in voiding pattern or urine characteristics. Ask the patient how much fluid he normally ingests each day, how much he ingested in the past 24 to 48 hours, and the time and amount of his last urination. Note a history of kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about abdominal, renal, or urinary tract surgery and about drug use.
Physical examination
Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Bladder distention:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If distention isn’t severe, begin by reviewing the patient’s voiding patterns. Find out the time and amount of the patient’s last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva’s or Credé’s maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient’s history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hematuria:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
After detecting hematuria, take a pertinent health history. If hematuria is macroscopic, ask the patient when he first noticed blood in his urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or end of urination? Has it occurred before? Is the patient passing any clots? To rule out artifactitious hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if there’s any pain or burning with the episodes of hematuria.
Ask about recent abdominal or flank trauma. Has the patient been exercising strenuously? Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history, noting any anticoagulants or aspirin.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Oliguria:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).
Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss, as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Anuria:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin by obtaining a complete history. First ask about any changes in the patient’s voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting especially previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about any abdominal, renal, or urinary tract surgery.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hematuria:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Hematuria without Proteinuria
Glomerular Disorders
Acute Postinfectious Glomerulonephritis
Usuallypresents within 1–2 wks after streptococcal pharyngitisor skin infection.Rare before 3 yrs of age.Disease spectrum varies from asymptomaticmicroscopic hematuria with normal renal function to acute renalfailure.Clinical manifestations include fever,abdominal or flank pain, edema, hypertension, and oliguria. Urinecolor is often reddish brown, and red cell casts are usually seen.Proteinuria may or may not occur. In almost all cases, C3 levelis decreased. Supporting evidence of preceding streptococcal infectioncan include positive throat culture, positive streptozyme, or elevatedantistreptolysin O titer.C3 level should return to normal withinabout 8 wks after onset of illness. Proteinuria can last for 6 mosand microscopic hematuria for 1–2 yrs, but virtually allchildren recover. Immunoglobulin A Nephropathy
Also knownas Berger disease.Can occur at any age, but peak incidenceis in adolescence and young adulthood.Usually presents with recurrent attacksof gross hematuria, which may be associated with upper respiratorytract infections.Microscopic hematuria can occur betweenepisodes of gross hematuria. Mild proteinuria also may occur, particularlyearly in the course. Renal function tends to be normal. Hypertension,nephrotic syndrome, and rapidly progressive course are unusual findings.Serum concentration of C3 is normal,and this helps to distinguish this disorder from acute postinfectiousglomerulonephritis. Immunoglobulin A is major immunoglobulin inmesangial deposits on renal biopsy. Henoch-Schönlein Nephritis
Common causeof vasculitis in childhood.Clinical features include abdominalpain, purpura on buttocks and lower legs, transient arthritis/arthralgiaof large joints, microscopic hematuria, and gastrointestinal bleeding.Diagnosis is usually clinical.Renal biopsy is indistinguishable fromimmunoglobulin A nephropathy.Some children develop chronic nephropathywith progression to end-stage renal disease. Alport Syndrome
Primaryfeature is recurrent gross hematuria or asymptomatic microscopichematuria. A number of affected children also have sensorineuralhearing loss. Later in life, individuals develop progressive renalinsufficiency.Usual form of genetic transmissionis X-linked, although autosomal-dominant and autosomal-recessiveforms occur. X-linked phenotype is due to mutation in the gene foralpha-5 chain of basement membrane collagen. Membranoproliferative Glomerulonephritis
Most commonin the second decade of life. 3 histologic types (I, II, III) havebeen described.Presentation is variable: gross ormicroscopic hematuria with or without proteinuria or nephrotic syndrome.Hypertension is common, and renal function may be decreased.Serum C3 level is usually low. C3 nephriticfactor may be present, especially in type II. Different types canonly be distinguished by renal biopsy. Systemic Lupus Erythematosus
Chronicmultisystem autoimmune disease that is most common in adolescent girls.Characteristic findings include fever,arthritis, weight loss, and nephritis. Hematuria and proteinuriaare common urinary findings. Antinuclear antibody is usually positiveand serum C3 is usually low.Antibody to double-stranded DNA isdiagnostic. Renal biopsy usually shows proliferative glomerulonephritiswith immunoglobulin G and C3 deposits. Familial Benign Hematuria (Thin Basement Membrane Nephropathy)
Autosomal-dominantdisorder in which hematuria is usually microscopic. Positive familyhistory of hematuria and absence of proteinuria suggest diagnosis.Electron microscopy shows thinning of glomerular capillary basementmembrane.Although thought to be benign, reportby Dische et al. (1985) described thin basement membrane nephropathyin several individuals who developed progressive renal disease.Further study is required to determine whether this disorder isreally benign. Nonfamilial Benign Hematuria
In many children, diagnostic studies do notreveal the cause of hematuria. These children are categorized ashaving benign nonfamilial hematuria. After months or years, hematuriafrequently disappears. Although this disorder is often benign, somechildren may have slowly developing glomerulonephritis. As longas hematuria exists, these patients should be tested at 6-mo intervalsto determine whether proteinuria develops.
Nonglomerular Disorders
Urinary Tract Infection
Common symptomsare dysuria, frequency, urgency, fever, abdominal pain, flank pain,and vomiting. Microscopic or gross hematuria can occur along withpyuria and bacteriuria.Positive urine culture confirms thediagnosis.See Chap.15, Dysuria. Trauma
Blunt orpenetrating injury to kidney or any portion of urinary tract cancause gross or microscopic hematuria.With minor trauma and microscopic hematuriain asymptomatic individuals, renal U/S should be performedto search for anatomic abnormality (e.g., hydronephrosis or renalcyst) because minimal trauma rarely causes hematuria in normal kidneys.Otherwise, CT is radiologic study of choice.Urethral trauma may occur followingcrush-type injury from fractured pelvis or direct injury, and urethrographymay be diagnostic. Exercise
Vigorous exercise can produce gross or microscopichematuria, which usually resolves within 1–2 days.
Hydronephrosis
In children with hydronephrosis, microscopicor gross hematuria may occur following mild flank or abdominal trauma.Renal U/S may be performed initially.
Renal Vein Thrombosis
Predisposingfactors include perinatal asphyxia, dehydration, septicemia, shock,and coagulopathies (e.g., protein C deficiency).Gross hematuria usually occurs alongwith palpable unilateral or bilateral flank masses.Renal U/S with Doppler methodsis diagnostic. Hemoglobinopathies
HemoglobinopathiesSA, SC, SS, CC, AC, and sickle beta-thalassemia can produce renalbleeding and microscopic or gross hematuria.Hemoglobin electrophoresis is diagnosticand should be performed in any African-American child with hematuriaof unknown cause. Idiopathic Hypercalciuria
Microscopicor gross hematuria may occur with increased urinary calcium excretion withoutevidence of urinary stone disease. However, hypercalciuria is riskfactor for development of urolithiasis.Urine calcium:creatinine ratio (mg:mg)of greater than normal for age can screen for this disorder (Matoset al., 1997). If spot ratio is greater than normal, 24-hr urinecalcium excretion should be measured. Calcium excretion of >4mg/kg/day is indicative of hypercalciuria. Urolithiasis
Causes inchildren include urinary tract infection, hypercalciuria, hyperuricosuria, cystinuria,and primary hyperoxaluria.When urinary stone is being passed,abdominal or flank pain (renal colic) and microscopic or gross hematuriaare usual findings.Diagnostic investigations should includeUA; urine culture; blood urea nitrogen; and serum measurements ofcalcium, phosphorus, uric acid, and creatinine.CT is recommended to search for underlyingdisease and localize any obstruction.When calculi are recovered from urine,their biochemical contents should be analyzed. If they are unrecoverablefrom urinary tract, determination of calcium:creatinine ratio inrandom urine specimen should be performed. Ratio greater than normalfor age can screen for hypercalciuria. More precise test is measurementof 24-hr urine calcium excretion.If these tests are negative, 24-hrurinary excretion of cystine, oxalate, and uric acid should be performed. Polycystic Kidney Disease
Autosomal-Recessive
Gene hasbeen mapped to chromosome 6.Common findings in neonates are grossor microscopic hematuria, bilateral flank masses, hypertension,and azotemia.Renal U/S usually revealslarge echogenic kidneys. Cysts are microscopic and not seen by imaging.Liver disease is congenital hepaticfibrosis.Diagnosis is usually clinical and radiologic. Autosomal-Dominant
Rarely encounteredin childhood.At least 3 different genetic mutationshave been found.Gross or microscopic hematuria, unilateralor bilateral abdominal masses, and hypertension are common findings.Abdominal U/S shows enlargedpolycystic kidneys and hepatic cysts.Diagnosis is usually based on clinicaland radiographic findings. Renal Tuberculosis
Usuallydoes not occur until primary disease has been established over several years.Usually associated with tuberculouscystitis, which can produce suprapubic pain and dysuria.Gross or microscopic hematuria andpyuria are characteristic.Mantoux test is usually positive.Usual urine culture for bacteria isnegative, whereas urine culture positive for acid-fast organismsis diagnostic. Vascular Malformations
Arteriovenousmalformations of kidney can present with gross hematuria.Renal U/S and CT may locatemalformation. Renal angiography is definitive. Foreign Body in Urethra or Bladder
Foreignbody in urethra or bladder usually produces urethral or suprapubicpain, dysuria, and hematuria.Abdominal radiography may reveal radiopaqueforeign body. Cystoscopy can confirm diagnosis.It is important to note that a foreignbody in the vagina can produce bleeding that may be mistaken forhematuria. Neoplasm
A numberof genitourinary neoplasms occur in the pediatric population.Wilms tumor, most common renal tumorin children, usually presents as abdominal or flank mass that doesnot cross midline unless it is very large. Gross hematuria occursin small number of cases. Renal U/S or CT shows renal massthat distorts collecting system.Renal hemangioma is rare lesion thatcan present with recurrent gross hematuria. Diagnosis is confirmedby renal angiography.Renal carcinoma is rare in pediatricpopulation, but renal U/S can demonstrate mass lesion.Bladder tumors are exceedingly rarein children, but suprapubic mass is sometimes palpable. Most commonbladder tumor is rhabdomyosarcoma, which can present with hematuriaor acute urinary retention. Abdominal U/S, CT, and cystoscopyare useful in locating and defining extent of tumor.In all cases of genitourinary tractneoplasms, histologic diagnosis is definitive. Bleeding Disorders
Although gross or microscopic hematuria mayoccur with bleeding disorders (hemophilias, thrombocytopenia, disseminatedintravascular coagulation), it is uncommon to have isolated hematuriaas only manifestation. See Chap.53, Recurrent Infection.
Drugs
A number of drugs (penicillins, sulfonamides,cephalosporins, rifampin, tetracycline, cisplatin, lithium) maycause gross or microscopic hematuria. Cyclophosphamide may causehemorrhagic cystitis.
Hematuria with Proteinuria
Hematuriawith proteinuria may occur with several glomerular renal disordersas discussed previously:Acute postinfectious glomerulonephritisImmunoglobulin A nephropathyHenoch-Schönlein nephritisAlport syndromeMembranoproliferative glomerulonephritisSystemic lupus erythematosus Other glomerular renal diseases thatusually present with hematuria and proteinuria are discussed inthis section. Membranous Nephropathy
Most commonduring second decade of life and usually presents with nephroticsyndrome. Microscopic hematuria is more common than gross hematuria.Renal biopsy confirms diagnosis. Glomerulonephritis of Chronic Infection
Disordersassociated with glomerulonephritis of chronic infection includeendocarditis and ventriculoatrial shunt infections.Clinical features are those of acuteglomerulonephritis, namely edema, hypertension, and renal insufficiency.Serum C3 is often decreased. Idiopathic Rapidly Progressive Glomerulonephritis
Uncommondisease in children; often preceded by viral illness.Affected children have acute onsetof hematuria, proteinuria, oliguria or anuria, and azotemia.Serum C3 level is normal or mildlydecreased. Many children progress to end-stage renal disease withina few weeks or months without treatment.Renal biopsy and clinical course arediagnostic. Hemolytic-Uremic Syndrome
Typicalform follows prodromal illness consisting of fever, vomiting, abdominal pain,and, often, bloody diarrhea. This is followed in 5–10 daysby hemolytic anemia with fragmented red cells, thrombocytopenia,and acute renal injury with hematuria, proteinuria, and often oliguriaor anuria.Most common pathogen is E. coli 0157:H7. Polyarteritis Nodosa
Necrotizingvasculitis that affects small and medium-sized arteries. Althoughcause is unknown, it may follow viral URI, streptococcal infection,or chronic hepatitis B infection.Characteristic findings include fever,abdominal pain, hematuria, hypertension, purpura, arthritis, andstroke.Lab findings include increased sedimentationrate, anemia, leukocytosis, proteinuria, and hypergammaglobulinemia.In some cases, antineutrophil cytoplasmic antibody is found.Biopsy demonstrating the vasculitisis diagnostic. Antiglomerular Basement Membrane Disease (Goodpasture Disease)
Associationof pulmonary hemorrhage and glomerulonephritis in which antibodies againstlung and glomerular basement membrane can be demonstrated.Characteristic findings are hematuria,proteinuria, hemoptysis, and progressive renal failure. Serum C3level is normal.Renal biopsy shows linear stainingof immunoglobulin G along glomerular basement membrane. Focal Segmental Glomerulosclerosis
Clinicallyindistinguishable from minimal change nephrotic syndrome but shouldbe suspected when there has been inadequate response to standardcorticosteroid therapy.Microscopic hematuria and occasionallygross hematuria may occur.Renal biopsy is diagnostic. Wegener Granulomatosis
Disorderof unknown cause characterized by vasculitis that affects upperand lower respiratory tract and kidneys.Fever, malaise, weight loss, hemoptysis,dyspnea, hematuria, and proteinuria are characteristic findings.Antineutrophil circulating antibodiesthat bind to proteinase 3 are specific for this disorder. Sinus,airway, lung, or kidney biopsy that shows necrotizing granulomatouslesions and presence of specific antineutrophil circulating antibodiesthat bind to proteinase 3 confirm the diagnosis. Diagnostic Approach
First stepin diagnosis is to determine whether there is blood in urine. Althoughblood may produce pink, red, or brownish color of the urine, othersubstances also may produce same type of urinary discoloration.Urine dipstick detects hemoglobin containedin red cells as well as free Hgb. It can detect as few as 1 or 2red cells per high-power field in uncentrifuged specimen. Microscopydetermines whether red cells are in urine and thus the presenceof hematuria.Urine sample that tests positive ondipstick but negative on microscopy indicates presence of hemoglobinor myoglobin. Serum is pink in color with hemoglobinuria and normalin color with myoglobinuria.Best way to distinguish myoglobin fromHgb is immunochemically. Red, orange, or brownish urine that isdipstick negative for blood indicates that certain foods (blackberries,beets), food dyes, urate crystals, or drugs (pyridium, desferoximine)are coloring urine. Urine containing porphyrin initially has normalcolor but changes to red on standing; dipstick is negative, andno red cells are seen on microscopy. Hematuria without Proteinuria
Microscopichematuria without proteinuria is most commonly due to urinary tractinfection, trauma, acute postinfectious glomerulonephritis, immunoglobulinA nephropathy, familial benign hematuria, or nonfamilial benignhematuria.Following history and physical exam,these tests should be performed initially: UA of child and familymembers (to diagnose familial benign hematuria), urine culture,serum creatinine, blood urea nitrogen, C3, calcium:creatinine ratio,and renal U/S. If results of these tests are normal, andproteinuria is consistently absent, most causes of hematuria havebeen excluded and further diagnostic studies (e.g., cystoscopy andrenal biopsy) are usually unnecessary.Children categorized as having nonfamilialbenign hematuria because they have normal evaluation and no recognizablerenal disease may prove to have transient hematuria, but as longas hematuria occurs, these children should be followed for possibleoccurrence of proteinuria. Those with familial benign hematuriaalso should be followed.In addition to above tests, diagnosticevaluation of gross hematuria should include CBC, platelet count,antistreptolysin O or streptozyme titer, and Hgb electrophoresis(in African-American children). Renal angiography may be necessaryif vascular malformation is suspected. If proteinuria occurs whenhematuria subsides, renal biopsy may be indicated. Hematuria with Proteinuria
Glomerulonephritisshould be suspected in every child with hematuria and proteinuria.Presence of red cell casts indicatesglomerular bleeding.Results of tests for urinary protein(urine dipstick, sulfosalicylic acid test) are usually positivewith gross hematuria. Although dipstick protein reading of 3+ to4+ may signify glomerular disease with gross hematuria,lower reading may have diagnostic significance. See Chap. 50, Proteinuria, forprotein concentrations corresponding to dipstick readings.To more reliably detect proteinuriaassociated with glomerular disease, urine should be tested whengross hematuria subsides.Renal biopsy is required for specificdiagnosis unless there is evidence of unequivocal acute postinfectiousglomerulonephritis or family history of Alport syndrome. Biopsymay be necessary with acute postinfectious glomerulonephritis ifserum C3 level does not become normal within 2 mos, if proteinuriapersists for >6 mos, or to distinguish it from idiopathicrapidly progressive glomerulonephritis if presentation is that ofacute renal failure.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Bladder distention:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If distention isn't severe, begin by reviewing the patient's voiding patterns. Find out the time and amount of the patient's last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva's maneuver or Credé's method to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient's history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs and herbal medicines.
Take the patient's vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can't be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Hematuria:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
After detecting hematuria, take a pertinent health history. If hematuria is macroscopic, ask the patient when he first noticed blood in his urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or end of urination? Has it occurred before? Is the patient passing clots? To rule out artifactitious hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if there's pain or burning with hematuria episodes.
Ask about recent abdominal or flank trauma. Has the patient been exercising strenuously? Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history, noting anticoagulants or aspirin.
Begin the physical examination by palpating and percussing the abdomen and flanks. Next, percuss the costovertebral angle (CVA) to elicit tenderness. Check the urinary meatus for bleeding or other abnormalities. Using a chemical reagent strip, test a urine specimen for protein. A vaginal or digital rectal examination may be necessary.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Oliguria:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).
Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.
Begin the physical examination by taking the patient's vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.
Obtain a urine specimen and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Anuria:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Take the patient's vital signs and obtain a complete history. First, ask about changes in his voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about abdominal, renal, or urinary tract surgery.
Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
HEMATURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical picture will point to the diagnosis in many cases. If
there is a history of abdominal trauma, a contusion or laceration of the
kidney or bladder should be suspected. Massive trauma anywhere prompts a
tentative diagnosis of crush syndrome. Purpura or bleeding from other sites
suggests a coagulation disorder. Severe colicky pain in the abdomen suggests
kidney stone. A long history of hypertension suggests polycystic kidneys, renal
artery stenosis, or glomerulonephritis. A history of fever and rheumatic
valvular disease suggests SBE with renal embolism. Painless hematuria in an
otherwise healthy looking adult suggests neoplasm, whereas painful hematuria
with frequency and dysuria suggests cystitis. Hematuria and a flank mass
would make a neoplasm or polycystic kidney likely.
The initial workup should include a CBC, urinalysis, urine culture,
chemistry panel, flat plate of the abdomen to assess the presence of stones
and kidney size, and personal examination of the urinary sediment. If a
renal calculus is suspected, an IVP is ordered immediately and a urologist
consulted. A three-glass test will help to localize the site of the
bleeding. If there is blood in the initial specimen only, the urethra is
probably the site of bleeding. If the blood is primarily in the final
specimen, the bladder is most likely the site of bleeding. Equal blood
discoloration in all specimens points to a renal lesion.
If renal TB is suspected, an acid-fast bacillus (AFB) smear and culture is
done. If collagen disease is suspected, an ANA analysis and
anti–double-strand DNA antibody titer is ordered.
If a renal carcinoma is suspected, a CT scan of the abdomen is probably the
best study to order, but the advice of a urologist ought to be sought.
Ultrasonography is useful in differentiating cysts from tumors. If a bladder
neoplasm is suspected, cystoscopy will be done. If renal artery embolism or
thrombosis is suspected, renal angiography may need to be done to clearly
make the diagnosis.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
ANURIA AND OLIGURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical picture will be helpful in determining the cause of
anuria. In cases of prerenal azotemia, there will be decreased skin turgor
and orthostatic hypotension if the cause is volume depletion. If the cause
is CHF, there will be jugular vein distention, hepatomegaly, and pedal
edema. Patients with postrenal azotemia may have an enlarged prostate, a
distended bladder, and other signs of obstructive uropathy. Patients with
renal azotemia may have bilateral flank masses (polycystic kidney),
hypertension, peripheral emboli (embolic glomerulonephritis), or a rash
(collagen disease, interstitial nephritis).
The initial workup includes a CBC; urinalysis; urine culture and
sensitivity; personal examination of the urine for casts, and so forth;
chemistry panel; spot urine sodium; serum and urine osmolality; flat plate
of the abdomen for kidney size; chest x-ray; and ECG. The bladder is
catheterized for residual urine; if this is significant, postrenal azotemia
is likely and a urologist is consulted. He will most likely do a cystoscopy
and retrograde pyelography after the patient’s condition is stabilized. Ultrasonography can be used to
determine if there is significant residual urine also.
The laboratory studies will determine whether there is prerenal or renal
azotemia. If the sodium concentration in the spot urine is less than 10
meq/L, prerenal azotemia is likely. Also, in prerenal azotemia, the
BUN/creatinine ratio is 20:1 or greater and the urine osmolality is 450 mOsm
per kilogram of water or greater. The urine sediment will show granular and
red cell casts in most cases of renal azotemia, and the BUN/creatinine ratio
will be 10:1 or less.
Further workup will depend on what the presumptive diagnosis is. If volume
depletion is the cause, intravenous saline and plasma volume expanders are
given while carefully monitoring the urine output. If this is ineffective,
furosemide and a mannitol drip can be utilized to reestablish urine output.
If these measures are ineffective, the patient obviously has a renal cause
for his or her anuria, and a urologist should be consulted.
Renal causes can be differentiated by further workup. If intravascular
hemolysis is suspected, a serum haptoglobin test should be ordered. If dissecting aneurysm or bilateral renal artery
stenosis is suspected, aortography and angiography would be done. If
polycystic kidney disease is suspected, ultrasonography or CT scan of the
abdomen may be done. Eosinophilia of the blood or urine will be found in
drug-induced nephritis. If a collagen disease is suspected, one should order
an ANA, double-stranded DNA (dsDNA) antibody titer, or lupus erythematosus
cell prep. A renal biopsy may also be necessary in these and many other
disorders.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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