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| Gross haematuria with blood clot in tubing after the insertion of CBD. at this moment, no need to do anything yet as the cause is obvious. if the bleeding continues, then proceed with irrigation. |
Walking through the ward, you will come across a
patient with Folley’s catheter and CBD bag connected to it. Haematuria as i
have being described in Image of The Day
7: Renal Mass [link] could be a disaster as it is due to the neoplasm. However, it is only one
out of more than 30 spectrum of disease that resulting from systemic, kidney,
ureter, bladder and urethra. For today’s image of the day, i will discuss on
traumatic haematuria.
In patient with already pre-existing catheter, the
first thing that should come into your mind is a traumatic haematuria secondary
to catheter insertion. Apart from the direct trauma due to the technique, the
catheter itself can sometime cause irritation to bladder mucosa in certain
patient. It is usually mild and not require any intervention. All you need to
do is to observe the condition and KIV for bladder irrigation if not resolving.
In patient with no pre existing catheter who presented
with hematuria, take note on these things. 1) To obtain information about any
surgical procedure that patient has undergone. Patient with stenting placement
post cystoscopy may cause minor bleeding. 2) History of transurethral
resection of the prostate and bladder tumor resection may explain the
hematuria. 3) Patient undergone laparotomy or pelvic surgery especially in
obstetric and gynecology case may have iatrogenic injury to the bladder and
ureter during the manipulation.
Last in the list for traumatic haematuria is trauma associated injury. Bear in minds that
all trauma patient must be inspected for bleeding from urethra meatus. While
monitoring for urine output is crucial for trauma patient, Folley’s catheter
insertion is an absolute contraindication for this type of patient until
retrograde urethrogram has being performed to exclude urethral injury.
Hematuria in trauma patient may be due to renal parenchymal injury or secondary
injury to either bladder or urethra due to pelvic fracture.
Differential diagnosis of non traumatic haematuria
(will not going to be discussed in this entry) would be URINARY TRACT INFECTION, stone, tumor, anticoagulation, structural
abnormalities (especially polycystic kidney), prostate lesion,
glomerulonephritis, enterovesical fistula, vascular pathology (renal
infarction, renal vein thrombosis, AVM), renal papillary necrosis, hemorrhagic
cystitis (a/w cyclophosphamide, chemotherapy with cytoxan), radiation cystitis,
connective tissue disease, tuberculosis, sickle cell disease, contamination
from menses and benign essential heamaturia.
When you examine the patient, look for any
discoloration of the flank or suprapubic area, any bloody discharge from
urethra, “free floating prostate” on per rectal examination that indicate
urethral disruption and pelvic examination to rule out co –existence/ source
with cervical bleeding.
Investigation should be ordered as according to the
most likely diagnosis and aetiology. Routine examination would be FBC,
coagulation study, UFEME (most of the time shows RBC only. But look for the
present of cast as well), BUSE. Other radiological investigation may include
plain abdominal x ray, retrograde urethrogram, KUB Ultrasound cytoscopy.
If the haematuria is not associated with urethral
injury and the haematuria is gross, then put the three way catheter and
irrigate with at least 6 pints of Normal Saline/ 24 hours and re evaluate the
patient. Non resolving haematuria will require further irrigation and detailed
evaluation. Anti fibrinolytic agent like Tranexamic acid can be used in life
threatening or severe haematuria before proceed with invasive modality.
Finally, please remember that even though that the
haematuria is likely due to trauma in origin, please NEVER FORGET about the non trauma cause of haematuria. Think a way
to exclude them! And always remember that UTI is also a common cause of
Haematuria in patient with CBD and female!!
Reference: Alan T. Lefor, Leonard G. Gomella et al, “Surgery
On Call”, 4th edition, Lange, 2006.
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