Hematuria

HEMATURIA, the excretion of urine with an admixture of red blood cells in a quantity detectable by the naked eye (bloody urination, "macroscopic hematuria") or with the help of a microscope ("microscopic hematuria"), is one of the most important symptoms of diseases of the urinary organs. An admixture of blood in the amount of 1 cubic centimeter per liter already gives a visible change in the color of the urine. Microscopic hematuria is observed predominantly in diffuse and focal acute and chronic nephritis, more precisely in diffuse and focal glomerulonephritis (see Nephritis) and in diffuse kidney lesions caused by various poisonings (alcohol, arsenic, mercuric chloride, cantharidin, etc.). Insignificant amounts of red blood cells are also detected in the urine in nephrosclerosis (more precisely, in arteriolosclerosis of the kidneys) and in congested kidneys due to heart failure, as well as in healthy individuals after heavy physical exertion, for example, after long marches (in war, the so-called "Marschhämaturie" of German authors). In all these cases, hematuria is usually accompanied by albuminuria and cylindruria, but not necessarily. In pyelitis, microscopic hematuria is also observed in the acute stages, with the constant presence of both leukocytes and epithelial cells in the urine. Finally, microscopic hematuria can be observed in subjects suffering from kidney stones, even in periods free from attacks. In any case, the appearance of even an insignificant amount of red blood cells represents a serious symptom that is subject to comprehensive evaluation. Macroscopic hematuria, or bloody urination, is observed most often in surgical diseases of the urogenital sphere (see below). In therapeutic practice, macroscopic hematuria has great diagnostic significance in severe acute diffuse glomerulonephritis, which often proceeds with the excretion of relatively large amounts of blood in the urine (the color of "meat washings"). Along with hematuria, the following are detected in the urine: albuminuria, all kinds of casts (including so-called "blood casts"), and a number of other formed elements. A type of chronic nephritis is encountered relatively rarely, which is characterized by periodic severe hematuria ("nephritis haemorrhagica dolorosa"). Acute hematuria, usually accompanied by painful sensations in the region of one kidney, is also observed in renal infarctions, most often in connection with an existing valvular heart defect and ulcerative endocarditis. In diseases of the urinary tract and in so-called surgical diseases of the urinary organs (including tuberculosis and neoplasms), blood can be admixed with urine in all sections of the urinary tract. G. Lang. The etiological factors causing the appearance of hematuria are traumatic injuries, local and general inflammatory diseases, local circulatory disorders, certain types of neoplasms, and intoxications. The urinary sphere can be traumatized along its entire extent both from the outside and from the inside. In this case, the intensity of the bleeding, like the degree of damage, is not in direct proportion to the force of the trauma, but depends on the organ being traumatized and its condition at the moment of the trauma. A discrepancy between the intensity of hematuria and the force of the trauma is also observed when the trauma is applied from the inside and can be explained by the better or worse protection of the organ, or the greater or lesser development of the subcutaneous fat layer. Local inflammatory diseases of the urinary organs can be the cause of both profuse and insignificant hematuria. In this case, the intensity of hematuria is in direct proportion to the character and activity of the inflammation. Acute inflammatory phenomena cause significantly more intense hematuria than chronic inflammations. The most profuse hematuria is usually observed as a result of tuberculous inflammation of the organ parenchyma. The degree of organ damage in hematuria of an inflammatory nature is not only not in direct proportion to the intensity of the bleeding, but, on the contrary, profuse bleeding in renal tuberculosis is almost constantly one of the symptoms of the initial stage of the disease. Moving on to hematuria caused by local circulatory disorders, first of all, one should mention renal hematuria during displacement of the kidney, which is usually insignificant; and venous bladder hematuria ex vacuo after careless emptying of an atonic bladder with a catheter, which is usually profuse and often life-threatening to the patient. Next, one should point out bleeding from the venous plexus of the prostate during acute urinary retention in individuals suffering from hypertrophy of the prostate gland. These bladder and prostatic venous hematurias are distinguished by the dark, almost brown color of the effused blood and their profuseness. Arterial bleeding from the urinary tract on the basis of local circulatory disorders is an extreme rarity (Gramenitsky). Hematuria depending on tumors of the urinary organs can be both profuse and insignificant; in this case, the amount of blood in the urine cannot by any means serve as a basis for prognosis. The most severe hematuria is caused by benign neoplasms—papillomas. A constant, insignificant admixture of blood in the urine serves as an indication, in combination with other symptoms, of the existence of a disintegrating neoplasm—cancer, sarcoma. Profuse, recurrent hematuria that appears suddenly and also disappears suddenly most often indicates accidental damage to the integrity of one of the villi of a papillomatous tumor of the bladder. Rare in their etiology are cases of parasitic hematuria and cases of hematuria in hemophiliacs. Furthermore, a number of cases of unilateral renal hematuria have been described in the literature under the uninformative name "essential hematuria" (i.e., cases of renal bleeding where the etiological factor that caused such bleeding could not be established). In the very recent past, the question of the etiology of such hematuria has undergone a radical revision (Fronshtein, Kholtsov, Gotlib, Scheele). Apparently, there can no longer be any doubt that the failure to find changes in kidneys operated on for profuse hematuria must be explained not by the absence of such changes, but by the insufficient thoroughness of histological examination. Essential hematuria as such does not exist, and in all cases described under this name, phenomena of either incipient nephritis or hemorrhagic pyelitis could have been established. Finally, there also exist paradoxical hematurias, occurring during attacks of acute inflammation of the vermiform appendix (Gotlib), which disappear upon the subsidence of the attack and resume again upon relapses of the disease. Frisch explains the onset of such hematuria by embolism of the vessels of the right ureter and kidney. It is sometimes possible to establish the site of blood admixture in the urine based on observation of the act of urination; sometimes a topical diagnosis can be made based on the appearance of the voided urine, based on its microscopic examination, and finally, based on comparing the bleeding with other clinical data. By having the patient urinate into three portions, one can observe a uniform coloration of all three portions of urine in a blood-red color, or the admixture of blood will be macroscopically detectable in the first or last portions of the urine. Microscopically, it is usually possible to confirm in such cases the presence of red blood cells in all three portions of the urine. A macroscopic admixture of blood only to the first portion of urine indicates a disease of the anterior urethra. Usually in such cases, before urination, as well as after its completion, blood begins to drip from the canal. The causes of urethral hematuria are traumatic injuries of the urethra as a result of a bruise, a fall, during sexual intercourse, or the careless, rough introduction of instruments. In such cases, confirmation of the diagnosis is found in the anamnesis, or one should assume the existence of a neoplasm in the urethra. The diagnosis is confirmed by urethroscopy. An admixture of blood exclusively to the first portion of urine is explained by the fact that the urine, which does not contain erythrocytes, while passing along the bleeding surface of the mucous membrane of the canal, washes off the blood clots located on it and is colored by them. In cases of bleeding from the posterior part of the urethra, the blood encounters an obstacle at the external sphincter, easily overcomes the weak internal sphincter, flows into the bladder, and, gradually mixing with the urine, colors it entirely. Besides neoplasms, bleeding from the posterior part of the canal can be caused by calculi located in it (which will be accompanied by frequent urination), traumatic injuries of the prostate as a result of the introduction of instruments, and venous hyperemia of the hypertrophied gland. An admixture of blood exclusively to the last portion of urine is usually accompanied by painful tenesmus and indicates a lesion of the bladder outlet, regardless of whether it is an inflammatory process or a neoplasm. In the case of a neoplasm, a gradual increase in symptoms is observed; in the case of inflammation, hematuria appears suddenly. A uniform coloration of all three portions of urine with blood indicates that the admixture of blood occurs in the bladder or the upper urinary tract. In this case, blood clots encountered in the urine can sometimes give a fairly accurate indication of the site of bleeding and the etiological factor that caused the latter.

In cases of bleeding from the bladder, the effused blood is either evenly distributed throughout the entire mass of urine or forms large clots of irregular shape. In renal bleeding, the clots often have an elongated shape, to which the characteristic name of 'blood worms' has been assigned. The explanation for the appearance of such worms should be sought in the fact that the blood effused into the renal pelvis manages to coagulate therein before mixing with the urine. The formed soft blood clot is carried by the flow of urine into the ureter, stretches along its narrow lumen, and takes on its shape. Some authors point to the significant importance of microscopic examination of urine for the topical diagnosis of hematuria. Thus, Senator believes that the predominance of leached erythrocytes in the urine indicates a renal origin of hematuria. However, it would be more correct to think that the appearance of erythrocytes during microscopic examination of the urinary sediment indicates not so much the place of their admixture as the duration of their stay in the bladder. The clarification of accompanying clinical phenomena is of enormous importance for the topical and etiological diagnosis of hematuria. The appearance of hematuria after strenuous movements or physical exertion and its disappearance during a resting position should arouse suspicion of the existence of a calculus in the urinary tract. In this case, other subjective symptoms are also often observed—pain, increased frequency of urination. The appearance of such hematuria is explained by the displacement of the stone from its usual bed and injury to the surrounding walls of the organ. Increased muscular tension itself, even without any calculus in the urinary tract, can cause hematuria. Such hematuria is usually encountered in individuals suffering from a floating kidney. In these cases, the following phenomenon is observed: the evening portion of urine contains an admixture of blood, while it cannot be detected in the morning urine. The explanation for this phenomenon is as follows: during movements, the kidney, due to its weight and the increased compliance of the fatty capsule, descends somewhat and is displaced from its usual bed. A kinking of the blood-draining vessels occurs, which, in turn, causes venous hyperemia and, consequently, bleeding from the congested organ. During rest, in the lying position of the organism, the kidney returns to its place, and the renal hyperemia that caused the hematuria disappears. From the above, it is evident that the character of hematuria in kidney stones is similar to the character of hematuria in a floating kidney, and the reference points for differential diagnosis, besides data from radiographic examination, should be sought in the following: if in a floating kidney hematuria disappears completely during the patient's complete resting position, then in the existence of a kidney stone, even during complete rest, it is possible to detect isolated erythrocytes in the centrifuged urinary sediment. Hematuria accompanied by pyuria and increased frequency of the act of urination indicates an inflammatory disease of the bladder mucosa. Also, long-lasting hematuria with pyuria and dysuria should always arouse suspicion of a tuberculous lesion (confirmation of the diagnosis is the finding of Koch's bacilli in the urine). Painless, profuse hematuria, appearing suddenly and disappearing just as suddenly, arouses suspicion of the existence of a polyp in the bladder, and the finding of tumor particles in the form of villi in the urine provides confirmation of the diagnosis. The same profuse, painless hematuria, appearing without visible causes and disappearing quickly without such causes, is also observed in neoplasms of the kidney, especially in hypernephromas. A negative result of urine examination for the presence of leukocytes, Koch's bacilli, and tumor villi, phenomena of cachexia, and the presence in the urine of peculiar epithelial cells resembling fat droplets always compel one to assume the existence of a kidney tumor. Thus, it is often possible to establish both a topical and an etiological diagnosis of hematuria based solely on questioning the patient, examination of the urine, and external examination of the patient. But the most reliable method for diagnosis is undoubtedly cystoscopy and catheterization of the ureters. In certain types of hematuria (data from anamnesis, exclusion of nephritis, hemophilia, general infection), a cystoscopic examination should be performed, which is the only reliable diagnostic method for many diseases. In these cases, one should not wait with cystoscopy until the blood in the urine disappears, because this reduces the possibility of establishing an accurate topical diagnosis. This may especially apply to cases of renal hematuria on the basis of tuberculosis or neoplasms. In the existence of an initial stage of kidney lesion, it will become extremely difficult to establish, after the disappearance of blood from the urine, which of the paired organs was bleeding. Often, immediately upon the introduction of the cystoscope, it is possible, based on the picture presented to the eyes, not only to localize the place of blood admixture to the urine but also to diagnose the disease that caused the bleeding. Profuseness of hematuria is not a contraindication to cystoscopy: usually, with the help of an irrigation cystoscope, it is possible to wash the bladder sufficiently so that the examination of its cavity, the inlet and outlet openings, does not present difficulties. Joseph proposed, in cases of profuse hematuria, to perform cystoscopy while filling the bladder with vaseline oil, in which blood does not dissolve. The prognosis of hematuria depends entirely on the nature of the affliction that caused it. Therapy depends entirely on the etiology and localization of the disease and must be directed directly toward the elimination of the cause that triggered the bleeding. In the vast majority of cases of hematuria in surgical diseases of the kidneys, such treatment consists of surgical measures—both from the field of major and minor surgery. Upon removal of a stone, neoplasm, excision of the bleeding organ in its entirety, after cauterization, lavages, catheterization—hematuria disappears. In a number of cases of hematuria caused by venous congestion, intoxications, inflammatory phenomena of the renal parenchyma, it is possible to stop the bleeding with therapeutic measures: dietetics, baths, etc.