2022年医学专题—症状学12.尿频血尿(1).ppt

Symptoms and signs of the kidney and urinary system,第一页，共三十六页。,Slide 2,Symptoms and signs of the kidney and urinary system,Alterations in urine composition(haematuria,proteinuria,bacteriua,leucocyturia,calculi)Disorders of Micturation(frequency,urgency,dysuria,incontinence,retention)Disorders of Urine volume(oliguria,anuria,polyuria)Loin dull pain(pyelonephritis,obstruction),renal colic(acute obstruction)Oedema(hypoalbuminaemia,salt and water retention)Symptoms of Uraemia(nausea,vomiting,lethargy),第二页，共三十六页。,血尿,Haematuria,第三页，共三十六页。,Slide 4,Hematuria,DefinitionCausesLocalization and pathogenesisAssociated symptomsEvaluation of HematuriaCase study,第四页，共三十六页。,Slide 5,Definition of hematuria,Microscopic evaluation of urinary sediment:freshly voided(10ml),centrifuged(1500 rpm for 5 min)urine sediment:RBC3/HP on at least 2 out 3 collected specimensDipstick test：free hemoglobin&myoglobin,need confirmationTwo Types of HematuriaGross hematuria(1ml/l):bright red,tea-colored brown or coca colaMicroscopic hematuria:the urine is clear,RBC can be seen under a microscope or tested in a lab(by flow cytometry).,第五页，共三十六页。,Slide 6,Pseudohematuria,Menstruating femalePigmenturia:presence of colored substance in the urine.Endogenous:myoglobin(breakdown of muscle;pink,red,brown or black)HemoglobulinExogenousDrugs:phenytoin(red urine),rifampin(yellow-orange to red),metronidazole,nitrofurantoin(brown),warfainFoods:beetroots(red),berries,rhubarb(yellow to brown or red),第六页，共三十六页。,Slide 7,Causes of Hematuria,Kidney and urinary tract diseases Glomerulonephritis(GN):IgA nephropathy,Membranoproliferative GN,Crescentic GN,FSGS,Renal vasculitis.Lupus nephritis,Schonlein-Henoch nephritis,acute Poststreptococcal GNInfection:Pyelonephritis,Cystitis,Urethritis,prostatitis,TBStone:kidney,Ureter,bladder,urethraTumors:kidney,Ureter,bladder,prostateHereditary disease:Alperts syndrome,Thin glomerular basement membrane nephropathy,Polycystic kidney diseaseRenal vessel diseases:Arterial emboli or thrombosis,Renal vein thrombosis,Arterial or venous malformation Others:Interstitial nephritis,papillary necrosis,trauma,第七页，共三十六页。,Slide 8,Causes of Hematuria,Systemic diseasessystemic coagulation disorders:TTP,platelet defect,coagulation protein deficiency,therapeutic anticoagulationInfectious diseases:SBE,severe infectious diseaseMalignant HTN,DN,AmyloidosisPhysical injury and chemical toxication vigorous exercise:marathon runningNut cracker syndromeIdiopathic hematuria,第八页，共三十六页。,Slide 9,Localization of Hematuria,Glomerular HematuriaFrom the renal parenchymaNon-glomerular HematuriaFrom the renal pelvis,ureters,bladder,or urethra(urinary tract bleeding),第九页，共三十六页。,Slide 10,Glomerular Hematuria,GN or tubulointerstitial nephritisPathogenesisSmall breaks in the GBM Rupture of tubular basement membraneDysmorphic hematuria（80%)Fragmented,distorted RBC,knoblike projections(passing through gaps of GBM)The degree of dysmorphism may be influenced by the urine osmolality,PH in the tubule and the time from passage of urineOther clues:significant proteinuria(1g/d),red cell casts,hypertension and edema,第十页，共三十六页。,Slide 11,Non-glomerular Hematuria,Infection,tumor,stone,trauma or arteriovenous malformationsDue to inflammation of mucosa,disruption of small vessels and erosion of urinary tractUniform bioconcave shape isomorphic(80%normomorphic)Other clinical clues:loin pain,superpubic pain,passage of clots(not be encountered in patients with glomerular disease),第十一页，共三十六页。,Detection Method,flow cytometry:automated method uncentrifuged unine samplesScreen large numbers of samples in a short timesamples of particular complexity for which a microscopic analysis is preferablephase contrast microscopy:observer dependent,第十二页，共三十六页。,Three-glass test,gross hematuria with normomorphic erythrocyturia,In the first 10-15ml urine:the urethraIn the final 10-30ml urine:a small hemorrhage from the trigone region of the bladderIn all three samples:the kidney or profuse bleeding from the bladder,Slide 13,第十三页，共三十六页。,Slide 14,Associated symptoms,Pain:loin dull pain(kidney stone),acute colic(kidney,ureter stone)Frequency,Urgency and dysuria:cystitis,urethritis,pyelonephritis,prostatitis,TB,tumorAbdomenal mass:renal tumor,polycystic kidney disease Bleeding tendency:hematologic disordersFever:acute pyelonephritis,TBHTN,edema,proteinuria:GNChyluria(white milky urine):filariasis,TB,tumorAsymptomic:IgA nephropathy,TBM nephropathy,tumor,第十四页，共三十六页。,Slide 15,History taking,Rule out pseudohematuria(drug,food,menstruation)Pattern of hematuriaBleeding of other organs:coagulation disturbancePast history of the kidney,urinary tract and prostate:HTN,proteinuria,edema,renal dysfunctionFrequency,Urgency and dysuriaHistory of drug ingestion:analgesics,antibiotics,anticoaulantsvigorous exercise,urethral catheterizationFamily history of renal disease,hematuria,deafness and polycystic kidney disease,第十五页，共三十六页。,Slide 16,Evaluation of Hematuria,History and physical examExclude pseudohematuria,vigorous exerc