The number of these cells is greatly increased in acute tubular necrosis. (vi) Casts - Red cell casts

syndrome, familial recurrent haematuria. 12. Renal embolization/infarction. 13. Analgesic nephropathy. 14. Unknown origin -Essential haematuria ("renal epistaxis"). Loin pain/haematuria syndrome. Ureter - (1) Trauma. (2) Calculi. (3) Infection. (4) Tumours - papilloma, carcinoma Prostate - Benign hypertrophy, carcinoma Bladder - (1) Diverticulum. (2) Trauma - following prostatectomy or other operations or instrumental. (3) Calculus or foreign body. (4) Tuberculosis. (5) Tumours - Simple, papilloma, carcinoma. (6) Ulcers. (7) Chemical cystitis - e. g. after cylophosphamide. (8) Parasitic - Schistosomiasis, Bancroftian filariasis. Urethra - (1) Malformations. (2) Injuries. (3) Calculus or foreign body. (4) Infections. (5) Tumours. (6) Naevus 2. Systemic causes - 1. Bleeding diathesis. 2. Collagen disorders - SLE, PAN. 3. Subacute infective endocarditis 4. Cryoglobulinemias. 5. Amyloidosis. 6. Acute fevers - Malignant malaria. 7. Tuberous sclerosis (associated angiomyolipomata). 8. Severe exertion (e. g. jogging). INVESTIGATION OF A CASE OF HAEMATURIA History - 1. Age - Newborn - haemorrhagic disease due to deficiency of vitamin K. Child - Acute nephritis, acute leukemia, acute infectious fevers, scurvy, haemophilia, bladder stone, meatal ulcer Young adults - Renal calculus or tuberculosis, gonococcal urethritis Middle or old age - Bladder tumours, congenital cystic kidneys, calculus, hypernephroma and other malignant tumours, hypertension, enlarged prostate 2 Sex - Bladder stone almost always in males. 3. Family history - of polycystic kidneys or urinary calculi. 4. Drugs - History of taking anticoagulants, sulphonamides or large doses of aspirin. 5. Previous history - of pulmonary or bone and joint tuberculosis. 6. Quantity of blood - Profuse in tumours of kidney or bladder injury with rupture of kidney. Rarely tuberculosis and enlarged prostate. 7. Precipitating cause - Trauma. Jolting or exercise in renal calculus. Instrumentation Intercourse. 8. Timing of bleeding in relation to urinary stream - Terminal haematuria preceded by clear urine suggests source in bladder, initial haematuria followed by clear urine is indicative usually of lesion in urethra. Haematuria equally distributed throughout the urinary flow is characteristic of renal and ureteric lesions, but may occur in bleeding from the bladder. 9. Pain - (i) Colicky in stone. (ii) Loin pain suggests renal cause. (iii) Pain at tip of penis especially after micturition indicates irritation of trigone. (iv) Pain in pen'neal area - malignant disease of bladder or prostate. (v) Hypogastric pain in cystitis. (vi) In Dietl's crisis, severe pain but haematuria rare. Haematuria precedes pain in tuberculosis and new growth of kidney, follows pain in renal stone. 10. Absence of pain - Enlarged congested prostate, early stage of malignant disease of bladder, renal neoplasms, congenital cystic kidneys, tuberculosis and systemic causes. Painless, periodic, progressive and profuse haematuria in simple papilloma. 11. Increased frequency of micturition - Local causes in bladder, tuberculosis or pyelitis. 12. Constitutional symptoms - Fever in pyelitis and cystitis Rash or eruption in acute fevers. 13. Haemorrhage elsewhere in the body - in purpura, haemophilia, fevers, hypertension Physical examination - (a) Local examination - 1. Palpation of kidneys - (i) Unilateral tumour - in tuberculosis, hypernephroma, hydro- or pyo-nephrosis (ii) Bilateral in polycystic disease. 2. Bladder tumour is occasionally palpable. 3. Inspection of external genitals and urinary meatus for local causes. 4. Examination of testis and epididymis for evidence of tuberculosis. 5. Rectal examination - Enlarged prostate, stone in bladder in children. 6. Vaginal examination - pelvic tumour, e. g. malignancy of uterus. (b) General examination -Examination of heart for SBE Blood pressure. Signs of anaemia Bruising or other evidence of haemostatic defect. Abdominal palpation for splenomegaly, enlarged kidneys or distended bladder Investigations - 1. Urine - (i) Excess of crystals of uric acid, oxalates, etc , may indicate presence of stones. (ii) Albuminuria and epithehal cells in acute nephritis. (iii) Pus cells in pyelitis and tuberculosis. (iv) Red cells - In glomerular bleeding there is great variation in size and many cells show loss of normal haemoglobin pigment. In non-glomerular bleeding the cells are uniform in appearance and usually have normal haemoglobin content (except in acid urine). (v) Renal tubular epithelial cells - A sharp rise in these cells may be produced by certain drugs The number of these cells is greatly increased in acute tubular necrosis. (vi) Casts - Red cell casts or casts containing red cells imply glomerular disease Granular casts, oval fat bodies and broad, waxy casts imply an underlying renal lesion. (vii) Culture - Pyuria with no growth on urine culture occurs with tuberculosis, tumours of urinary tract and analgesic nephropathy. (viii) Cytology -when urothelial neoplasm is suspected. 2. Blood examination - for evidence of hypoprothrombinemia, purpura or haemophilia. 3. Chest X-ray - for evidence of malignancy or tuberculosis. 4. IVU - may provide evidence of silent cysts or renal tumours Appearance suggesting papillary necrosis indicates analgesic nephropathy but may occur in diabetes, sickle-cell disease or obstructive uropathy. 5. Cystoscopy - If IVU and urine culture are normal Upper urinary tract bleeding is usually unilateral Bladder tumours and pre-malignant papillomata can be diagnosed by cystoscopy, with biopsy when necessary 6.