Approach to haematuria and dysuria

• Definition of haematuria

  Blood in the urine.
• Definition of haemoglobinuria

  Haemoglobin in the urine.
• Definition of myoglobinuria

  myoglobin in the urine (looks brown/orange).
• Definition of bilirubinuria

  Bilirubin in the urine (yellow/ orange colour).
• Definition of dysuria

  Difficulty or pain on urinating
• Definition of stranguria

  Straining to urinate.
• Definition of Pollakiuria

  Frequent urination
• Definition of Oliguria

  Minimal urine production.
• Definition of anuria

  No urine production
• Definition of incontinence

  An inability to control urination.
• Why are female animals typically more prone to urinary tract infections than their male counterparts?

  Due to a shorter, wider urethra
• What does urinalysis tell us - dipstick

  Blood/Hb positive.

  Poorly specific, but dots are supportive of blood, whereas homogenous change is supportive of haemoglobin/ myoglobin.
• What does urinalysis tell us - sediment exam

  Centrifuge the sample.

  RBCs will precipitate, cytology confirms RBCs present.

  Haemoglobin/myoglobin will not precipitate, cytology does not demonstrate RBCs.
• We need to rule out haemoglobinuria and myoglobinuria

  Blood sample and centrifuge.

  • Plasma likely to be red with haemoglobinaemia.
  • Plasma likely clear with myoglobinaemia.
  • Test for muscle markers (AST and CK).

  Both products end up in the urine due to being at high levels in the blood and being filtered by the nephrons.
• Bloody urine - is it haematuria?

  RBCs on sediment exam.

  Clear (ish) plasma and centrifuged urine.

  Presence of regenerative anaemia may be supportive of haemorrhage.

  What and why is there bleeding?

  • Damage to vessels
  • Abnormal haemostasis.
• What to do with a diagnosis of haemoglobinuria or myoglobinuria?

  Haemoglobinaemia:

  • Haemolysis -> see pre-hepatic jaundice and haemolytic disease.

  Myoglobinaemia:

  • Severe muscle damage
  • AST/CK, History, exam.
  • Physical causes - trauma/ burns/ strenuous exercise/ prolonged immobility.
  • Non-physical causes - hypoxic/ischaemic/metabolic disturbances/infectious.
• Where could blood in the urine of come from in cats and dogs?

  Damaged kidneys, bladder, urethra (anywhere in our urinary tract), also reproductive tracts.
• Why might something be bleeding?

  Neoplasia

  Imflammation

  Coagulopathy (manifest in haematuria)
• Creating a differentials list for haematuria - damage to vessels

  Trauma - history and exam.

  Urolithiasis - urine sediment exam, ultrasound, radiography (contrast).

  Urinary tract infection (including prostatic):

  • urine sample - cytology and C+S
  • Ultrasound

  Inflammation - history, urinalysis, imaging to rule out other causes.

  Neoplasia:

  • CBC - chronic anaemia
  • Ultrasound and radiography
  • Endoscopy and biopsy
• Creating a differentials list for haematuria - abnormal haemostasis


  Coagulpathy:

  • CBC; platelet count and PT, aPTT, TEG

  Neoplasia (abnormal vessels)

  • CBC, imaging, biopsy.

  Idiopathic:

  • Idiopathic renal haematuria
  • Rule out everything else
  • CBC for anaemia
  • Ureteroscopy.
• Idiopathic renal haematuria

  Uncommon. Typically in large breed, young dogs. Unilateral in 75% of cases. Caused by vascular anomalies is some humans.

  Haematuria: potentially passing clots, or seeing them in bladder via ultrasound.

  Can lead to: anaemia, renal pain, ureteral pain and/or ureteral obstruction; UTIs.

  Treatment:

  • ACEi (for proteinuria) and ARBs
  • Potentially interventional radiography - sclerotherapy.
• What do we see clinically with dysuria? how is it different to haematuria?

  History or a video of the animal urinating is useful, both stranguria or pollakiuria Amy have pain as a component, but stranguria is prolonged, painful straining and owners may report ’ a drop at a time’ or tenesmus.

  Many differentials are common to both - anything that stimulates pain or inflammation.

  Dysuria is due to lower urinary tract disease - whereas discoloured urine can be form anywhere on the urinary tract.
• Stranguria - obstructive disease

  Failure of bladder to empty (neuromuscular).

  • Detrusor atomy - overstretch and damage - flaccid, easy to express.
  • UMN bladder (thoracolumbar disease) - urethral sphincter tone remains high, preventing urination, difficult to express.
  • Inflammatory, infectious, iatrogenic can all have a big bladder
• Stranguria - non-obstructive disease

  Anatomical - e.g. ectopic ureters

  Neuromuscular - e.g. USMI

  Inflammatory, infectious, iatrogenic, idiopathic.

  FIC
• Blocked bladder - exploratory laparotomy

  Allows direct visualisation - neoplasia.

  Allows for biopsy/ sampling/ curative surgery.

  Technical expertise for procedures otherwise major complications;

  • Bladder mass incisional biopsy - uroabdomen.
  • Bladder mass excisional biopsy - curative.
• Blocked bladder - endoscopy

  Allows for direct visualisation (via a screen)

  • Ectopic ureters
  • Neoplasia
  • Idiopathic renal haematuria (identify the ureter).

  Allows for biopsy/ sampling.

  Reduced risk of trauma - but can perforate a fragile bladder.

  Technical expertise - specialist training to use and interpret.