Hematuria is the most common symptom of urological diseases, which can be divided into visual and microscopic hematuria. A small amount of red blood cells can be found in the urine of a normal healthy person. Take 10 ml of clean and fresh intermediate urine, centrifuge at 1500 rpm for 5 minutes, and take the sediment for microscopic examination. 0~2 red blood cells/high magnification field (HP) can be found in a normal person, and hematuria can be diagnosed when there are >3 red blood cells/HP. When the amount of blood contained in urine exceeds 1 ml/L, hematuria of the naked eye is seen.
I. Etiology and pathogenesis
Inflammation, malformations, stones, trauma and tumors in various parts of the urinary system can cause hematuria. Hematuria is most often caused by immune damage to the glomerular basement membrane; it may also be caused by exudative inflammation due to direct invasion of pathogenic bacteria; hematuria due to structural abnormalities of collagen fibers and chemical components of the basement membrane itself is seen in hereditary nephritis; hematuria due to direct destruction of renal and urinary tract vessels by renal vasodilatation, stasis, thrombosis, stones, tumors, etc.; hematuria due to systemic hematologic disorders due to coagulation mechanism. Currently, according to the morphology of urine red blood cells, hematuria is divided into glomerular and non-glomerular hematuria. Glomerular hematuria is caused by hematuria from the glomerulus, while non-glomerular hematuria is caused by hematuria from the urinary system below the glomerulus.
II. Diagnosis
(A) Symptoms
1.Localization of hematuria: initial hematuria suggests that the lesion is in the urethra; terminal hematuria suggests that the lesion is in the bladder neck and triangle, posterior urethra; whole hematuria suggests that the lesion is in the kidney, ureter or bladder.
2.To determine whether it is true hematuria: pseudohematuria can be seen in non-urinary tract bleeding, red urine such as food-baiting, hemoglobinuria, myoglobinuria, certain metabolites of the body and drugs.
3.Persistent: persistent microscopic hematuria is mostly found during physical examination or urinalysis for other diseases.
4.Recurrence: The main manifestation is recurrent episodes of carnal hematuria, each time lasts for 2~5 days, and the interval between episodes varies from several weeks to several years, with normal urinary routine or microscopic hematuria between episodes. There are also intermittent microscopic hematuria due to infection or exertion as a trigger.
5. Concomitant symptoms and medical history: history of antecedent infection before onset; family history of renal disease; concomitant symptoms such as fever, rash, arthralgia, painful urination, deafness, etc.; history of medication use.
(ii) Physical signs
Physical examination: growth and development status, hypertension, edema, rash, abdominal mass, kidney area percussion, deafness, genitalia with or without prepuce.
(C) Laboratory tests
1.Urinary routine: centrifugal urine RBC>3/HP, non-centrifugal urine RBC>1/HP, more than 3 times with pathological significance.
2.Addis count: collect 3 hours of urine in the early morning and calculate 1 hour urinary excretion rate of organic fraction. Adult RBC: male < 30,000/HP, female < 40,000/HP, pediatric RBC excretion rate is about 2 times that of adults.
3, urine red blood cell morphology: urine sediment added to 3% glutaraldehyde fixative 1ml, 1 hour after taking a drop on the slide, room temperature natural drying, Richter staining, ordinary light oil microscopy observation, when the red blood cell morphology is budding, ring, perforation and other changes, known as severely deformed red blood cells, when it is greater than 30% or more is called renal hematuria, such as homogeneous red blood cells mainly, severely deformed red blood cells less than 15% considered as non-nephrogenic hematuria. Recently, our hospital carried out the application of centrifugal urine after the sediment with phase contrast microscopy, abnormal red blood cells greater than 80% of the consideration of glomerular hematuria.
4, urinary calcium measurement: when urinary calcium/urinary creatinine>0.21, then further measurement of 24-hour urinary calcium quantification, when urinary calcium>4mg/kg.d or 0.1mmol/kg.d, then hypercalciuria is suspected.
5.Medium urine culture + drug sensitivity + colony count
6.Blood routine and corresponding blood system examination
7.Other renal hematuria related labs: ASO, complement, hepatitis B five, renal function, anti-nuclear antibody, etc.
8. Abdominal ultrasound: and check for nutcracker phenomenon
9. intravenous pyelogram
10. Renal biopsy: suitable for glomerular hematuria
(D) Differential diagnosis
1. Glomerular hematuria.
(1) Primary glomerular diseases: such as acute and chronic glomerulonephritis, nephrotic syndrome, acute progressive nephritis, IgA nephropathy, congenital hereditary glomerular diseases, etc.
(2) Secondary glomerular diseases: such as systemic lupus erythematosus nephritis, allergic purpura nephritis, hepatitis B-associated nephritis, hemolytic uremic syndrome, pulmonary hemorrhagic nephritis syndrome, etc.
(3) Mononeural hematuria.
(4) Transient hematuria after strenuous exercise.
2.Non-glomerular hematuria
(1) Urinary tract infection.
(2) Urinary calculi and idiopathic hypercalciuria.
(3) Left renal vein compression syndrome (Nutcracker phenomenon).
(4) Congenital renal and vascular malformations: such as polycystic kidney, bladder diverticulum, arteriovenous fistula, hemangioma, etc.
(5) Tumor, trauma and foreign body.
(6) Drug-related hematuria: such as cyclophosphamide, sulfonamides, aminoglycoside antibiotics.
(7) Infections such as tuberculosis, protozoa, spirochetes, etc.
(8) Hemorrhage caused by systemic diseases: such as thrombocytopenic purpura, natural bleeding in newborns, hemophilia, etc.
(9) Glomerular hilar vasculopathy: refers to abnormalities of blood vessels at all levels from the hilum to the glomerulus, mainly malformations or fistulas. It may be clinically asymptomatic or with recurrent meatus hematuria. Confirmation of the diagnosis requires imaging examination.
III. Treatment
The treatment after diagnosis varies according to the original disease, and simple hematuria does not require treatment.
1, post-streptococcal infection nephritis: remove the foci of infection, symptomatic and treat complications.
2.Drug hematuria: stop the drug and protect kidney function
3.Urological tumor, foreign body, etc.: surgical assistance for treatment.