Symposium on Radiology in Internal Medicine
Hematuria P. Ruben Koehler, M.D.,* and Myo M. Kyaw, M.D.**
The presence of either gross or microscopic blood in the urine is a danger signal that must not be ignored. Yet frequently, particularly in patients whose hematuria is transient and painless, a false sense of security and complacency results in significant delay before a thorough examination is undertaken. Because of the high incidence of association of hematuria with potentially curable malignancy, the physician is obliged to pursue the matter until a competent and complete examination either yields a definitive diagnosis or excludes the presence of a detectable lesion causing the hematuria. Though gross hematuria is more alarming than microscopic hematuria, it is not unusual to find lesions which at first produce microscopic hematuria and later larger amounts of blood. Therefore microscopic and macroscopic hematuria must be considered equally serious symptoms. In most instances, a definitive diagnosis can be reached, but there is a significant number of patients in whom the organ causing the bleeding is identified, but in whom no specific diagnosis can be made, despite careful examinations. In these patients, repeated x-ray examinations are mandatory before one is justified in concluding that he is dealing with "idiopathic hematuria." Hematuria is a symptom, not a disease. Knowing whether the hematuria is initial, terminal or present throughout urination is often helpful in determining the site of bleeding. Initial hematuria is usually associated with anterior urethral lesions such as urethritis and stenosis, and with foreign bodies. Terminal hematuria usually arises from a lesion in the posterior urethra, bladder neck or trigone; common causes are urethritis, tumors of the vesicle neck and occasionally prostatitis. Total hematuria has its source at, or above, the bladder level. When hematuria is associated with renal colic it strongly suggests the presence of renal or urethral calculus. However, a clot from a bleeding tumor may also cause the same type of pain. Hematuria associated with dull back pain and fever is suggestive of infection. Hematuria without any other symptoms-painless or silent hematuria-must be From the Department of Radiology, University of Utah College of Medicine, Salt Lake City *Professor of Radiology Professor of Radiology
**Associate
Medical Clinics of North America- Vol. 59, No. 1, January 1975
201
202
P.
RUBEN KOEHLER AND MyO M. KYAW
regarded as a symptom of tumor of the bladder, ureter or kidney, until proved otherwise. Figure 2 illustrates, in a schematic way, causes of gross hematuria. The data is based on Lee and Davis' series of 1000 patients; it is noteworthy that in 220 patients the cause was cancer of the urinary tract.
RADIOGRAPHIC EXAMINATIONS OF PATIENTS WITH HEMATURIA The most useful examination-the one which must be employed in every patient with hematuria-is the intravenous urogram (Fig. 1). For many patients this may be the only radiographic examination needed. The diagnosis of stones, infections and many tumors of the kidney can be made by intravenous urography. If the pelvocalyceal system is inadequately visualized, one may resort to the retrograde injection of contrast medium. Although retrograde pyelography has been almost completely replaced by safer and easier high volume intravenous urography, it is still useful in patients with poor renal function and helpful when it is not possible to visualize one or more of the calyces. When the intravenous urogram suggests a space-occupying lesion, one can better outline the area in question with the help of body-section radiography, also called tomography. Coordinated movements of the xray tube and the film carrier bring out selected layers of the questionable area by placing them in relief from the blurred overlying structures. This method used in conjunction with the intravenous injection of large volumes of contrast medium results in the so-called nephrotomogram. The films are exposed approximately 30 seconds after the intravenous injection, during the time when the vascular bed of the kidney is perfused. In this manner, one can frequently distinguish avascular masses such as cysts from vascular masses such as malignant tumors. Cysts will appear relatively lucent while tumors will show no lucency when one compares the density of the mass as it relates to the normal kidney tissue. Recently, ultrasonography has been added to the armamentarium of diagnostic modes used in the evaluation of renal masses. Ultrasound in medicine is a noninvasive means of measuring normal and abnormal structures within the body. The frequencies used are in the range of millions of cycles per second. These high frequency waves are beamed into the tissue and are reflected and refracted by the interfaces between different densities of organs. Whenever a propagated wave hits an interface, parts will be reflected and parts will be refracted. The amount of penetration of the sonic beam depends on the medium encountered. Homogeneous media such as fluid-filled cysts allow the ultrasound beam to penetrate well. On the other hand, the less homogeneous the medium is, the more difficult it is for the wave to penetrate, since reflection and refraction are continuously diminishing the intensity of the beam as it travels through the nonhomogeneous medium. These differences in the wave propagation can be recorded on a cathode ray tube and allow for differentiation between the benign cyst and a solid mass (see Figures 14 and 15).
HEMATURIA
203
Figure 1. Normal intravenous urogram. The smooth outline of both kidneys can be seen. The calyces are dilated ; infundibula, renal pelvis, and ureters are filled. This film was taken about 20 minutes after the injection of contrast medium, and the urinary bladder is filled with the contrast agent.
Probably the most sophisticated radiographic examination is the renal angiogram. Angiography is the technique employed for visualizing the vascular bed of the kidney or bladder. When related to hematuria, it is primarily used to differentiate a benign cyst from a malignant tumor. It is less frequently employed in the diagnosis of inflammatory disease. Because of the nonspecificity of the pyelogram, angiography must be undertaken in all patients in whom the diagnosis "idiopathic hematuria" is suggested. Angiography can also be used when the renal pelvis or ureter are completely obstructed, and urographic examination fails to demonstrate the cause of obstruction. Angiography is useful in the evaluation and work-up of patients with acute renal trauma or changes secondary to remote trauma, or when arterial thrombosis, rupture, perirenal hematomas or fractures of the renal parenchyma are suspected. While diagnos-
204
P.
RUBEN KOEHLER AND MyO M . KYAW
KIDNEY
15%
URETER 6% CANCER -..,_ _~"
15%
CYSTITIS
22%
BENIGN HYPERTROPHY CANCER _-'lA.J\lIloI""-_
2%
12%
PROSTATITIS
BLADDER 40%
PROSTATE
25%
10%
URETHRA 4%
Figure 2. Diagrammatic presentation of the common causes of gross hematuria (modified from Lee and Davis).
tic accuracy in the pathology of the upper tracts is high, angiography is of only limited value in demonstrating causes of heinaturia when lesions originate in the ureter, bladder, prostate or urethra. In all instances an intravenous urogram is the first examination which must be undertaken. It consists of a preliminary film of the abdomen and a series of films taken at various intervals following the intravenous injection of a suitable contrast medium (Fig. 1). The contrast medium is almost completely excreted by glomerular filtration. Factors affecting visualization are glomerular filtration rate, dehydration, rate of urine flow and volume of collecting system. A history of proved hypersensitivity contraindicates the intravenous urogram or any other radiographic examination which necessitates the injection of a contrast medium. The incidence of true hypersensitivity is low, but because severe reactions may take place, one must be familiar with the emergency treatment of these reactions before performing these tests. Shown in Figure 2 are the causes of hematuria. The most commonly encountered are infection, cancer, calculous disease, and trauma. Rare causes are collagen vascular disease, arteritis associated with drug abuse and sickle cell disease.
INFLAMMATORY DISEASE OF THE URINARY TRACT According to Lee and Davis, in about 4 per cent of patients, hematuria is due to inflammatory disease of the kidneys. This includes a variety of entities such as acute and chronic pyelonephritis, acute and
HEMATURIA
205
chronic glomerular nephritis, focal nephritis, renal tuberculosis, actinomycosis, and other fungal diseases. The radiographic diagnosis of acute pyelonephritis and acute glomerulonephritis is difficult and generally not specific. At times the kidneys may be enlarged and excretion somewhat impaired, but usually the intravenous urogram will be normal. As the disease progresses to the more chronic stages, a more specific picture emerges. Figure 3 shows the changes seen in chronic pyelonephritis. Since it is a focal disease, the degree of involvement of parts of the kidney varies. Generally, there will be a decrease in renal substance. The disease more commonly starts near the poles, and scar tissue formation results in irregularities and contraction of the renal outlines; calyces become blunted. These are the cardinal radiologic signs of chronic pyelonephritis. The process is bilateral, but the degree of involvement is not necessarily identical on the two sides. The diagnosis of chronic pyelonephritis is usually made without difficulty, but since hematuria is not a common manifestation of pyelonephritis, when it occurs one must be certain that other causes are not overlooked. The diagnosis of hematuria associated with chronic pyelonephritis is, therefore, one of exclusion. The radiographic changes of chronic glomerulonephritis are less specific. Usually one will see a small kidney with a slight decrease in the corticomedullary ratio. Patients with focal nephritis may have hematuria, but the intravenous pyelogram is normal. The diagnosis is based on biopsy material. Hematuria is common in patients with sickle cell disease and sickle cell trait. On the intravenous urogram, blunting and clubbing of calyces is seen. In addition, necrosis of papillae is observed (Fig. 4). Cystitis is the most common cause of hematuria. The diagnosis is made by cystoscopy. Generally the radiographic changes are minimal and the diagnosis cannot be made on the radiograph. Similarly, prostatitis is frequently associated with hematuria, but the diagnosis is a clinical one; there are no specific changes seen on radiographs.
CALCULI OF THE UPPER URINARY TRACT Urinary calculi may be radiopaque or radiolucent. The radiographic density of stones varies according to their salt composition. Stones composed of calcium oxalate are denser than those composed of calcium carbonate or phosphate. Stones composed of uric acid or ammonium, sodium and magnesium urates are frequently radiolucent. The presence or absence of symptoms depends on the location of the stone. In many instances, symptoms may be entirely absent, and calculus is discovered on the x-ray films taken because of hematuria. Both gross and microscopic hematuria are common signs. Symptoms will develop if the stone obstructs the urinary tract or if the urinary tract gets infected because of the stone. The classical signs of an attack are an acute renal or urethral colic with severe pain coming in waves and affecting the involved side. The diagnosis can be confirmed with the intravenous urogram. When the stone or stones are radiopaque, a calcific density is seen overlying the
206
P.
RUBEN KOEHLER AND MyO M. KYAW
Figure 3. Patient with bilateral chronic pyelonephritis. A, Intravenous urogram. Notice that the collecting system, particularly near the upper poles, reaches to the outer border of the kidney. The renal cortex at the lower pole is much better preserved. The asymmetrical focal involvement is typical of chronic pyelonephritis. B, Selective injection of the left renal artery. The distribution of the major intrarenal branches is fairly normal. There is an increase in tortuosity of the intralobar and intralobular arteries.
207
HEMATURIA
Figure 3 Continued. C, The loss of cortex around the upper calix (arrow) is better seen during the nephrographic phase.
kidney or ureter. If the examination is done during an acute attack, usually there will be a marked delay in excretion of the injected contrast material on the affected side. When compared with the normal side, the involved kidney parenchyma will appear denser (nephrogram). There is a delay in the filling and visualization of the collecting system. Because of the obstruction, the calyces are blunted. If films are taken for a sufficiently long period, the collecting system and ureter will fill to the point where the stone is lodged (Fig. 5). Generally, a retrograde pyelogram is not needed to confirm the diagnosis. The diagnosis of a radiolucent stone can only be made by intravenous or retrograde urography. In these patients, the plain film will be normal, but the delayed excretion and the obstructive changes described above will be seen (Fig. 6).
TRAUMA The degree of hematuria is a poor indicator of the severity of injury to the kidney; severe hematuria may be seen with only minor contusions as well as with massive lacerations. (Text continued on page 211.)
208
P.
RUBEN KOEHLER AND MyO M. KYAW
Figure 4. Intravenous urogram in a patient with sickle cell disease. This illustration shows the radiographic appearance of papillary necrosis. Several small medullary-type cavities (arrows) are seen adjacent to minor calyces. Notice that while the disease involves two of the calyces, the others appear normal. The presence of abnormal calyces adjacent to normal calyces is the rule and not the exception in patients with papillary necrosis.
HEMATURIA
209
Figure 5. A 45 year old patient with a history of urinary tract infection and occasional episodes of microscopic hematuria. The patient recently had an episode of gross hematuria which cleared after one day. A, Scout film taken prior to intravenous urogram; note calcifications over both kidneys. B, Film taken 10 minutes after the injection of contrast medium. The calcification in the right kidney is located within the lower calix (arrow). The calcifications on the left are within the minor calix of the upper calyceal group; a large composite stone almost completely occupies the lower calyceal group (arrow). Had the scout film of the abdomen not been taken, the calcifications could have easily been missed, because their density is almost identical to that of the excreted contrast medium.
210
P.
RUBEN KOEHLER AND MyO M. KYAW
FigurE) 6. A, Scout films of the abdomen show a calcific density (arrow) opposite the third lumbar vertebra in a 45 year old man who developed left flank pain. Urinalysis revealed multiple red cells. B, Intravenous urogram taken 75 minutes after injection. The collecting system on the right is normal. Note the dense nephrogram on the left side. There is only a little contrast medium in the collecting system. The ureter is not filled. This is a characteristic picture of obstruction in the ureter.
HEMATURIA
211
Figure 6 Continued. C, Film taken 3 ' /2 hours after injection. The stone has now moved to the level of the sacrum (arrow). The ureter and collecting system are filled up to that point. Generally, when a nephrogram can be seen (as in B), if films are taken over a sufficiently long period of time, the exact location of the stone can practically always be demonstrated.
Depending on the type of trauma, one can suspect where the injury to the urinary tract occurs. If the trauma involves the abdomen and the patient has hematuria, renal or urethral injury is most likely. If the patient has multiple pelvic fractures, injury to the bladder of the urethra is probable. Renal injuries may be classified according to their severity as concussions, ruptures, lacerations with or without the involvement of calyces and renal pelvis, and tears of the vascular pedicle. These potential injuries are shown schematically in Figure 7. The radiologic work-up depends on the clinical state. A patient who is in shock because of blood loss is generally too ill to undergo prolonged radiologic examination. If the plain film of the abdomen shows loss of the psoas muscle and a poor outline of the kidney, and if the patient's blood pressure and hematocrit are dropping, one should suspect a tear of the renal pedicle; the patient should be sent to surgery immediately. Because of the massive blood loss involved, tear of the vascular pedicle is the most life-threatening type of injury. If the patient's condition is stable, intravenous urography should be performed. Unfortunately, the intravenous urogram is a poor index to the extent of renal damage. On the intravenous urogram one searches for extravasation of contrast medium (Fig. 8). This will occur only if the injury involves the pelvocalyceal system. In a significant number of patients, deep lacerations, even fracture and fragmentation of parts of kidneys, may occur without injury to the pelvocalyceal system. In these patients
212
P.
RUBEN KOEHLER AND MyO M. KYAW
LACERATION OR RUPTURE
Figure 7.
Diagram for the purpose of classifying traumatic injuries to the kidney.
massive blood loss may occur, yet the urogram may appear close to normal. The true extent of injury to the kidney will not be appreciated unless an angiogram is done (Fig. 9). Leakage from the renal artery or its branches, displacement of vessels, or the presence of deep parenchymal clefts, will help to accurately assess the degree of injury. If, in an injured patient, the intravenous urogram is normal or almost normal, no severe blood loss is suspected, and the patient's condition is stable, one may elect to choose a "wait and see" attitude. If the patient's condition improves, no additional studies will be needed, but if signs of infection or chronic blood loss persist, an angiogram should be obtained. If the trauma primarily involves the bony pelvis, the status of the bladder and urethra must be ascertained. Clinically, the most important question is whether the patient can void. In patients who are able to void and have only little or no hematuria, the possibility of major damage to the lower urinary tract is remote. In all instances, the urethra should be examined. The most frequent point of laceration or transection of the urethra is the triangular liagment, where the urethra is relatively fixed to the symphysis. Ideally, examination of the urethra should be done before a catheter is placed in the bladder, since on occasion, the catheter may bridge a complete transection of the urethra. If contrast medium is injected through the urethra without a catheter, the point of injury to the urethra will be found. If the urethra is normal, the catheter can be placed in the bladder and the cystogram done. Most injuries to the bladder are intraperitoneal, but ruptures of the extraperitoneal portions are not rare and must be searched for. The bladder is not often injured during accidents unless it is distended at the time of trauma. Bony fragments, bullets or instruments are common agents causing injuries. Clinical signs of intraperitoneal ruptures are shock and (Text continued on page 217.)
Figure 8. A 42 year old woman who sustained injury to her left flank in a car accident; urinalysis showed gross hematuria. A, Film taken during intravenous urography approximately 5 minutes after injection of contrast medium. The collecting system on the left side is poorly seen. There is an accumulation of contrast medium around the lower pole. B, Arteriogra m done immediately follOwing the intravenous urogram shows a significantly injured left lower pole. There is a deep cleft (between arrows) in the renal parenchyma. Extravasated contrast medium on the intravenous urogram comes from the lacerated lower calix. The tip of the kidney is completely avulsed and the renal capsule (white arrows) is removed from the renal tissue. This illustrates severe injury to the kidney, the degree of which is difficult to evaluate on urography alone. The prognosis in an injury such as this is guarded; in this patient attempts to perform a heminephrectomy were not successful, and the kidney had to be removed.
213
214
P.
RUBEN KOEHLER AND l\1YO
M.
KYAW
Figure 9. This patient was involved in a car accident and sustained injuries to his right flank. Gross hematuria was present. A, Intravenous urogram shows extensive extravasation of contrast medium, which is found around the upper pole of the ,kidney, much of it being subcapsular. Laceration of the renal pelvis or the upper calix or both must be suspected in such circums tances.
HEMATURIA
215
Figure 9 Continued. B, Renal angiography done immediately after urography shows that most of the intrarenal branches are intact, although there is some spasm and poor perfusion of the upper pole. The extensive extravasation is not from the blood vessels, but rather from the pelvocalyceal system (i.e., urine). Based on the angiographic study, it was concluded that the damage was rather minor. The patient was treated conservatively and did well.
Figure 10. This patient sustained severe trauma to the pelvis; note that both pubic and ischial rami are fractured. The patient had gross hematuria. A, A balloon was inserted into the urinary bladder (B) and the bladder filled with contrast medium. Extravasation into the retroperitoneal space is apparent. B, The nature of the retroperitoneal extravasation was better appreciated after the contrast medium was drained from the bladder. The contrast medium, present in the retroperitoneal space, is scattered throughout the injured tissues; the borders are ill-defined. Because the medium is in a confined space it does not change even when the patient's position is changed. This type of distribution of contrast medium is characteristic of its presence in the retroperitoneum. A similar appearance will be seen if a ureter or urethra is injured and the contrast medium leaks into the retroperitoneal or pelvic soft tissues.
216
217
HEMATURIA
Figure 11. Large fungating carcinoma of the bladder. Note the ill-defined irregular right border of the bladder. The tumor extends to the trigonum; the right ureter is partially occluded. The ureter is widened because of the obstruction caused by the tumor (T).
signs of acute peritonitis. Microscopic or macroscopic hematuria is always present. The diagnosis can be made by cystoscopy or cystography. With intraperitoneal ruptures, contrast medium outlining the bowel can be seen. When the laceration is into the retroperitoneal space, a rather characteristic accumulation of contrast medium in the .retroperitoneum is seen (Fig. 10). The contrast will remain after the bladder is emptied.
TUMORS OF THE URINARY TRACT One out of every five patients with hematuria has a tumor. Most of the lesions are in the urinary bladder, and the diagnosis can be best made by cystoscopy. Tumors of the bladder can be demonstrated radiographically (Fig. 11). Tl1ey can be seen on late films taken during intravenous urography or on films taken during the cystogram. The filpls show filling defects and irregularities in the bladder. The extent, and occasionally the depth of invasion, can be demonstrated both by cystography and angiography; however, in most instances cystoscopy and thorough bimanual pelvic examination will suffice in establishing the diagnosis and extent of the disease. Renal masses can frequently be identified by changes in the kidney outline on plain films of the abdomen. However, even on intravenous urography, it is usually not possible to predict the nature of the mass. Deformity of the collecting system and changes in the outline of the kidneys will be seen in renal cell carcinomas and in benign renal cysts. If the tumor is peripheral, it may grow in an eccentric manner so that little or
218
P.
RUBEN KOEHLER AND MyO
M.
KYAW
Figure 12. Intravenous urogram in a patient with a ' single episode of gross painless hematuria. A mass with a calcific rim is noted in the lower pole of the right kidney (between arrows). This patient had a renal cell carcinoma.
no distortion of the internal architecture occurs. Mere displacement of the collecting system on the other hand does not mean that a malignant lesion is present. Single or multiple renal cysts, renal abscesses, as well as malignant tumors, all similarly affect the collecting system, and all can be associated with hematuria. Rim-like calcifications, although more frequently associated with malignant tumors, may be seen with benign cysts; however, stippled and amorphous calcifications are almost always signs of malignancy (Fig. 12). When technically good intravenous urograms are available, little additional information is gained from retrograde pyelography. In practically all instances, the radiologist can differentiate between benign and malignant renal mass lesions. Nephrotomography, angiography and ultrasound, as well as direct percutaneous puncture of the mass, may be done. Currently, our policy in working-up patients with renal masses is to perform an intravenous urogram. This examinagon is followed with ultrasonic scans. If the sc:m indicates the presence of malignant tumor, an angiogram is then performed (Figs. 13 and 14). This is to confirm the diagnosis and to outline the true extent of the lesion. When the ultrasound scan suggests a cystic mass, a percutaneous puncture is performed (Fig. 15); renal cysts will yield a clear yellow fluid, which is studied for the presence of malignant cells and elevation of lactic acid dehydrogenase and fat. If no malignant cells are seen and LDH and fat are low, the diagnosis of benign cyst is practically assured and no further treatment is needed. If the puncture yields bloody fluid or if suspicious cells are seen, an angiogram is done. Percutaneous puncture is a simple, safe and very reliable procedure. There is no evidence that punc-
219
HEMATURIA
o
Figure 13. A, Intravenous urogram in a patient with hematuria. A large mass is present on the upper lateral border of the left kidney (arrows). B, Typical arteriographic findings of renal cell carcinoma. Note the markedly irregular tortuous tumor vessels in the involved portion of the kidney.
220
P.
RUBEN KOEHLER AND MyO
M.
KYAW
Figure 14. Young adult with a history of several episodes of gross painless hematuria. Intravenous urogram was essentially normal. A, Selective right renal angiogram shows typical tumor vessels in the lower part of the right kidney (T). B, Ultrasonic examination was performed. This is a Polaroid print of a transverse scan done 6 cm above the iliac crest with the patient in the prone position. Note the echoes within the tumor (T arrow). The lower group of echoes represents the calyceal system, which is pushed downward. The large dark area in the middle represents the spine (S). Compare the findings of this study with Figure 15, which represents a benign cyst.
HEMATURIA
221
Figure 14 Continued. C, The same tumor studied in the A mode. Note that several spikes are present within the area of the tumor. These represent areas of sound refraction. Whenever such spikes are present within a mass, the diagnosis of a solid tumor must be made.
ture of a malignant tumor will result in any implantation of cells along the needle tract.23 Neoplasms arising in the renal pelvis, calyces and ureter comprise only 5 per cent of renal tumors. Histologically, they are transitional cell carcinomas - the same cell type as tumors of the urinary bladder. Hematuria, gross or microscopic, is the most common sign. Radiographically, these tumors are best demonstrated by intravenous or retrograde urography. They generally do not calcify or form large masses, and thus they cannot be detected on plain films of the abdomen. They grow primarily into the collecting system rather than into renal parenchyma. On intravenous or retrograde urography, the tumors appear as irregular filling defects occupying the renal pelvis or a calyceal group (Fig. 16). Less frequently, they will appear as small round persistent filling defects. Since they are usually associated with hematuria (blood clots in the renal pelvis may have a similar appearance), it is important to examine the patient after the hematuria has subsided to see if a filling defect persists. Because transitional cell carcinomas are poorly vascularized, angiography is far less reliable in their diagnosis than in the diagnosis of renal cell carcinomas. Tumors of the ureters are commonly associated with partial or complete urethral obstruction (Fig. 17). Other mass lesions which may cause hematuria are polycystic kidneys (Fig. 18), arteriovenous malformations (Fig. 19), renal abscesses, and spontaneous bleeding into the kidney, particularly in drug abusers, patients with collagen vascular disease, or patients who are being treated with anticoagulant medication. While the diagnosis of polycystic disease is fairly characteristic on intravenous urography (Fig. 18), the diagnosis of all other mass lesions is usually not characteristic enough on the intravenous urogram to allow a definitive diagnosis, and angiography will be necessary for the work-up (Fig. 19). (Text continued on page 232.)
222
P.
RUBEN KOEHLER AND MyO M. KYAW
Figure 15. A 23 year old man with a history of microscopic hematuria. A, Intravenous urogram shows a large mass in the lower pole of the left kidney (arrows). B, Selective renal arteriogram-arterial phase. Note the sharp demarcation between the normal kidney tissue and the mass. There are no pathological vessels seen.
HEMATURIA
223
Figure 15 Continued. C, On the nephrographic phase, the sharp demarcation between the normally vascular kidney and the avascular mass is clearly seen. This is the typical appearance of a benign cyst. Compare these findings with Figures 13 and 14 which show angiographic findings characteristic of a malignant tumor.
224
P.
RUBEN KOEHLER ANDMyO M. KYAW
Figure 15 Continued. D, Ultrasonic examination. Transverse scan taken 5 cm above the iliac crest with the patient prone. Note the sonolucent area on the left side. The posterior border is sharp, typical of a cyst Cc). The right kidney Ck) is smaller, and few echoes from the normal calyceal system are demonstrated within it. E, Longitudinal ultrasound scan taken 8 cm to the left of the midline. The cyst Cc) adjacent to the kidney Ck) is clearly seen. There are no .echoes within it.
225
HEMATURIA
.
I
•
I
F
,
Figure 15 Continued. F, A-mode scan shows no echoes within the cyst (between arrows). Compare the last three illustrations with the ones presented in Figure 14. It is apparent that the ultrasound characteristics of a benign cyst vary significantly from those of a malignant tumor. G, The cyst is punctured and water-soluble contrast medium is injected through the needle. Note the homogeneous distribution of the contrast medium and the sharp margins of the cyst. Had this been a tumor, the contrast medium would appear irregular with ill-defined borders. Histological examination of the aspirated fluid should be made. The levels of LDH and fat content are assessed ; in a cyst they are low, in a tumor they are high .
226
P.
RUBEN KOEHLER AND MyO M. KYA-W
Figure 16. Transitional cell carcinoma of the kidney. There are filling defects in the upper and mid calyceal groups, as well as in the upper margin of the renal pelvis. This is the characteristic picture of transitional cell carcinoma; however, blood clots, radiolucent stones, and infection may on occasion mimic this picture. A definitive diagnosis can be made if a catheter is placed in the ureter and the collected urine is examined for malignant cells.
HEMATURIA
227
Figure 17. Primary carcinoma of the ureter. The patient first sought medical advice because of left flank pain. Urinalysis demonstrated microscopic hematuria The diagnosis of a renal stone was suspected, but intravenous urography clearly shows an irregular polypoid mass present in the upper ureter. The histologic diagnosis was transitional cell carcinoma.
228
P.
RUBEN KOEHLER AND MyO M. KYAW
Figure 18. A, Intravenous urogram in a patient with polycystic disease. Note the bizarre appearance of the collecting system bilaterally. The calyces are spread and splayed around multiple masses. The kidneys measure 18 cm in length (normal is 12 to 14 cm). This is the typical appearance of polycystic disease. B, Selective renal arteriogram in a patient with polycystic disease. No tumor vessels are present, however, some of the intrarenal branches are splayed around filling defects.
HEMATURIA
229
Figure 18 Continued. C, The typical filling defects of polycystic disease are better seen in the nephrographic phase. The so-called "Swiss cheese" appearance is evident in this illustration.
230
P.
RUBEN KOEHLER AND MyO M. KYAW
Figure 19. Young adult with a history of one episode of painless hematuria. A, Intravenous urogram shows splaying of calyces in the upper and lower calyceal group. The picture is nonspecific, but a tumor was suspected.
HEMATURIA
231
Figure 19 Con tin ued. B, Selective renal arteriogram shows the presence of a congenital arteriovenous malformation.
232
P.
RUBEN KOEHLER AND MyO M. KYAW
SUMMARY In this brief presentation the more common causes of hematuria have been presented. The most frequent causes are cystitis, prostatitis other benign disease. Frequently this diagnosis is only one of exclusion: one must be certain that the hematuria truly originates from these relatively benign diseases. Hematuria should be regarded as a danger signal; the entire urinary tract must be examined carefully to rule out any other abnormality. In 20 per cent of the patients with gross hematuria, malignant tumors have been found; in many instances the tumors can be cured if detected early.
REFERENCES 1. Becker, J. A.: Transitional cell carcinoma of the renal pelvis: Causes of non-visualization on excretory urography. J. Urol., 101 :280--282, 1969. 2. Collins, H. A., and Jacobs, J. K.: Acute arterial injuries due to blunt trauma. J. Bone ]t. Surg., 43A: 193-197, 1961. 3. Dautrebande, J. G., Duckett, G., and Roy, P.: The claw sign of cortical cysts in renal arteriography: A contribution to the differential diagnosis of renal space occupying lesions. J. Canad. Assoc. Radiologists, 18:24-250, 1967. 4. Elkin, M.: Renal vascular shunts. Clin. Radiol., 22:156-170,1971. 5. Ettinger, A., et al.: Importance of selective renal angiography in the diagnosis of polycystic disease. J. Urology, 102:156-161, 1969. 6. Felson, B., and Moskowitz, M.: Renal pseudo-tumors: The regenerated nodule and other lumps, bumps and dromedary humps. Amer. J. Roentgenol., 107:720-729. 7. Ferris, T. F., et al: Recurrent hematuria and focal nephritis. New Eng. J. Med., 276:770775, 1967. 8. Fleming, R. J., and Stern, L. Z.: Multiple intraparenchymal renal aneurysms and polyarteritis nodosa. Radiology, 84:100-103, 1965. 9. Gill, W. M., and Pudvan, W. R.: Arteriographic diagnosis of renal parenchymal diseases. Radiology, 96:81, 1970. 10. Grablowsky, O. M., Weichert, R. F., and Goff, J. B.: Renal artery thrombosis following blunt trauma. Surgery, 67:895-900, 1970. 11. Grabstaldt, H.: Renal cell cancer. n. Diagnosis. N. Y. J. Med., 64:2658-2671,1964. 12. Grabstaldt, H., Whitmore, W. F., and Melamed, M. R.: Renal pelvic tumors. JAMA, 218: 845-854, 1971. 13. Harrow, B. R., Sloane, J. A., and Liebman, N.C.: Roentgenologic demonstration of renal papillary necrosis in sickle-cell trait. New Eng. J. Med., 268:969-976, 1963. 14. Hodson, C. J.: The radiological contribution toward the diagnosis of chronic pyelonephritis. Radiology, 88:857-871, 1967. 15. Jonsson, K.: Renal angiography in patients with hematuria. Amer. J. Roentgenol., 116:758-765,1972. 16. Lang. E. K., et al.: Arteriographic assessment of injury resulting from renal trauma: An analysis of 74 patients. J. Urology, 106:1-8,1971. 17. Lee, L., and Davis, E.: Gross urinary hemorrhage: Symptom, not a disease. JAMA, 153:782-784,1953. 18. Lindvall, N.: Renal papillary necrosis: Roentgenographic study of 155 cases. Acta Radiol., Supp. 192:1-153,1960. 19. Olsson, 0., et al.: Encyclopedia of Urology. Heidelberg: Springer-Verlag, 1962, pp. 165208. 20. Olsson, 0., and Lunderquist, A.: Angiography in renal trauma. Acta Radiol. Diag., 1 :1-21, 1963. 21. Peterson, C., Willerson, J. T., Doppman, J. L., and Decker, J. L.: Polyarteritis nodosa with bilateral renal artery aneurysm and perirenal haematomas: Angiographic and nephrotomographic features. Brit. J. Radiol., 43:62-71,1970. 22. Sullivan, M. J., Smalley, R., and Banowsky, L. H.: Renal artery occlusion secondary to blunt abdominal trauma. J. Trauma, 12:509-515, 1972. 23. Von Schreeb, T., Arner, 0., Skovsted, G., and Wikstad, N.: Renal adenocarcinoma: Is there a risk of spreading tumour cells in diagnostic puncture? Scan. J. Urol. Nephrol., 1 :270276, 1967.
Department of Radiology University of Utah College of Medicine Salt Lake City, Utah 84132
Hematuria P. Ruben Koehler, M.D.,* and Myo M. Kyaw, M.D.**
The presence of either gross or microscopic blood in the urine is a danger signal that must not be ignored. Yet frequently, particularly in patients whose hematuria is transient and painless, a false sense of security and complacency results in significant delay before a thorough examination is undertaken. Because of the high incidence of association of hematuria with potentially curable malignancy, the physician is obliged to pursue the matter until a competent and complete examination either yields a definitive diagnosis or excludes the presence of a detectable lesion causing the hematuria. Though gross hematuria is more alarming than microscopic hematuria, it is not unusual to find lesions which at first produce microscopic hematuria and later larger amounts of blood. Therefore microscopic and macroscopic hematuria must be considered equally serious symptoms. In most instances, a definitive diagnosis can be reached, but there is a significant number of patients in whom the organ causing the bleeding is identified, but in whom no specific diagnosis can be made, despite careful examinations. In these patients, repeated x-ray examinations are mandatory before one is justified in concluding that he is dealing with "idiopathic hematuria." Hematuria is a symptom, not a disease. Knowing whether the hematuria is initial, terminal or present throughout urination is often helpful in determining the site of bleeding. Initial hematuria is usually associated with anterior urethral lesions such as urethritis and stenosis, and with foreign bodies. Terminal hematuria usually arises from a lesion in the posterior urethra, bladder neck or trigone; common causes are urethritis, tumors of the vesicle neck and occasionally prostatitis. Total hematuria has its source at, or above, the bladder level. When hematuria is associated with renal colic it strongly suggests the presence of renal or urethral calculus. However, a clot from a bleeding tumor may also cause the same type of pain. Hematuria associated with dull back pain and fever is suggestive of infection. Hematuria without any other symptoms-painless or silent hematuria-must be From the Department of Radiology, University of Utah College of Medicine, Salt Lake City *Professor of Radiology Professor of Radiology
**Associate
Medical Clinics of North America- Vol. 59, No. 1, January 1975
201
202
P.
RUBEN KOEHLER AND MyO M. KYAW
regarded as a symptom of tumor of the bladder, ureter or kidney, until proved otherwise. Figure 2 illustrates, in a schematic way, causes of gross hematuria. The data is based on Lee and Davis' series of 1000 patients; it is noteworthy that in 220 patients the cause was cancer of the urinary tract.
RADIOGRAPHIC EXAMINATIONS OF PATIENTS WITH HEMATURIA The most useful examination-the one which must be employed in every patient with hematuria-is the intravenous urogram (Fig. 1). For many patients this may be the only radiographic examination needed. The diagnosis of stones, infections and many tumors of the kidney can be made by intravenous urography. If the pelvocalyceal system is inadequately visualized, one may resort to the retrograde injection of contrast medium. Although retrograde pyelography has been almost completely replaced by safer and easier high volume intravenous urography, it is still useful in patients with poor renal function and helpful when it is not possible to visualize one or more of the calyces. When the intravenous urogram suggests a space-occupying lesion, one can better outline the area in question with the help of body-section radiography, also called tomography. Coordinated movements of the xray tube and the film carrier bring out selected layers of the questionable area by placing them in relief from the blurred overlying structures. This method used in conjunction with the intravenous injection of large volumes of contrast medium results in the so-called nephrotomogram. The films are exposed approximately 30 seconds after the intravenous injection, during the time when the vascular bed of the kidney is perfused. In this manner, one can frequently distinguish avascular masses such as cysts from vascular masses such as malignant tumors. Cysts will appear relatively lucent while tumors will show no lucency when one compares the density of the mass as it relates to the normal kidney tissue. Recently, ultrasonography has been added to the armamentarium of diagnostic modes used in the evaluation of renal masses. Ultrasound in medicine is a noninvasive means of measuring normal and abnormal structures within the body. The frequencies used are in the range of millions of cycles per second. These high frequency waves are beamed into the tissue and are reflected and refracted by the interfaces between different densities of organs. Whenever a propagated wave hits an interface, parts will be reflected and parts will be refracted. The amount of penetration of the sonic beam depends on the medium encountered. Homogeneous media such as fluid-filled cysts allow the ultrasound beam to penetrate well. On the other hand, the less homogeneous the medium is, the more difficult it is for the wave to penetrate, since reflection and refraction are continuously diminishing the intensity of the beam as it travels through the nonhomogeneous medium. These differences in the wave propagation can be recorded on a cathode ray tube and allow for differentiation between the benign cyst and a solid mass (see Figures 14 and 15).
HEMATURIA
203
Figure 1. Normal intravenous urogram. The smooth outline of both kidneys can be seen. The calyces are dilated ; infundibula, renal pelvis, and ureters are filled. This film was taken about 20 minutes after the injection of contrast medium, and the urinary bladder is filled with the contrast agent.
Probably the most sophisticated radiographic examination is the renal angiogram. Angiography is the technique employed for visualizing the vascular bed of the kidney or bladder. When related to hematuria, it is primarily used to differentiate a benign cyst from a malignant tumor. It is less frequently employed in the diagnosis of inflammatory disease. Because of the nonspecificity of the pyelogram, angiography must be undertaken in all patients in whom the diagnosis "idiopathic hematuria" is suggested. Angiography can also be used when the renal pelvis or ureter are completely obstructed, and urographic examination fails to demonstrate the cause of obstruction. Angiography is useful in the evaluation and work-up of patients with acute renal trauma or changes secondary to remote trauma, or when arterial thrombosis, rupture, perirenal hematomas or fractures of the renal parenchyma are suspected. While diagnos-
204
P.
RUBEN KOEHLER AND MyO M . KYAW
KIDNEY
15%
URETER 6% CANCER -..,_ _~"
15%
CYSTITIS
22%
BENIGN HYPERTROPHY CANCER _-'lA.J\lIloI""-_
2%
12%
PROSTATITIS
BLADDER 40%
PROSTATE
25%
10%
URETHRA 4%
Figure 2. Diagrammatic presentation of the common causes of gross hematuria (modified from Lee and Davis).
tic accuracy in the pathology of the upper tracts is high, angiography is of only limited value in demonstrating causes of heinaturia when lesions originate in the ureter, bladder, prostate or urethra. In all instances an intravenous urogram is the first examination which must be undertaken. It consists of a preliminary film of the abdomen and a series of films taken at various intervals following the intravenous injection of a suitable contrast medium (Fig. 1). The contrast medium is almost completely excreted by glomerular filtration. Factors affecting visualization are glomerular filtration rate, dehydration, rate of urine flow and volume of collecting system. A history of proved hypersensitivity contraindicates the intravenous urogram or any other radiographic examination which necessitates the injection of a contrast medium. The incidence of true hypersensitivity is low, but because severe reactions may take place, one must be familiar with the emergency treatment of these reactions before performing these tests. Shown in Figure 2 are the causes of hematuria. The most commonly encountered are infection, cancer, calculous disease, and trauma. Rare causes are collagen vascular disease, arteritis associated with drug abuse and sickle cell disease.
INFLAMMATORY DISEASE OF THE URINARY TRACT According to Lee and Davis, in about 4 per cent of patients, hematuria is due to inflammatory disease of the kidneys. This includes a variety of entities such as acute and chronic pyelonephritis, acute and
HEMATURIA
205
chronic glomerular nephritis, focal nephritis, renal tuberculosis, actinomycosis, and other fungal diseases. The radiographic diagnosis of acute pyelonephritis and acute glomerulonephritis is difficult and generally not specific. At times the kidneys may be enlarged and excretion somewhat impaired, but usually the intravenous urogram will be normal. As the disease progresses to the more chronic stages, a more specific picture emerges. Figure 3 shows the changes seen in chronic pyelonephritis. Since it is a focal disease, the degree of involvement of parts of the kidney varies. Generally, there will be a decrease in renal substance. The disease more commonly starts near the poles, and scar tissue formation results in irregularities and contraction of the renal outlines; calyces become blunted. These are the cardinal radiologic signs of chronic pyelonephritis. The process is bilateral, but the degree of involvement is not necessarily identical on the two sides. The diagnosis of chronic pyelonephritis is usually made without difficulty, but since hematuria is not a common manifestation of pyelonephritis, when it occurs one must be certain that other causes are not overlooked. The diagnosis of hematuria associated with chronic pyelonephritis is, therefore, one of exclusion. The radiographic changes of chronic glomerulonephritis are less specific. Usually one will see a small kidney with a slight decrease in the corticomedullary ratio. Patients with focal nephritis may have hematuria, but the intravenous pyelogram is normal. The diagnosis is based on biopsy material. Hematuria is common in patients with sickle cell disease and sickle cell trait. On the intravenous urogram, blunting and clubbing of calyces is seen. In addition, necrosis of papillae is observed (Fig. 4). Cystitis is the most common cause of hematuria. The diagnosis is made by cystoscopy. Generally the radiographic changes are minimal and the diagnosis cannot be made on the radiograph. Similarly, prostatitis is frequently associated with hematuria, but the diagnosis is a clinical one; there are no specific changes seen on radiographs.
CALCULI OF THE UPPER URINARY TRACT Urinary calculi may be radiopaque or radiolucent. The radiographic density of stones varies according to their salt composition. Stones composed of calcium oxalate are denser than those composed of calcium carbonate or phosphate. Stones composed of uric acid or ammonium, sodium and magnesium urates are frequently radiolucent. The presence or absence of symptoms depends on the location of the stone. In many instances, symptoms may be entirely absent, and calculus is discovered on the x-ray films taken because of hematuria. Both gross and microscopic hematuria are common signs. Symptoms will develop if the stone obstructs the urinary tract or if the urinary tract gets infected because of the stone. The classical signs of an attack are an acute renal or urethral colic with severe pain coming in waves and affecting the involved side. The diagnosis can be confirmed with the intravenous urogram. When the stone or stones are radiopaque, a calcific density is seen overlying the
206
P.
RUBEN KOEHLER AND MyO M. KYAW
Figure 3. Patient with bilateral chronic pyelonephritis. A, Intravenous urogram. Notice that the collecting system, particularly near the upper poles, reaches to the outer border of the kidney. The renal cortex at the lower pole is much better preserved. The asymmetrical focal involvement is typical of chronic pyelonephritis. B, Selective injection of the left renal artery. The distribution of the major intrarenal branches is fairly normal. There is an increase in tortuosity of the intralobar and intralobular arteries.
207
HEMATURIA
Figure 3 Continued. C, The loss of cortex around the upper calix (arrow) is better seen during the nephrographic phase.
kidney or ureter. If the examination is done during an acute attack, usually there will be a marked delay in excretion of the injected contrast material on the affected side. When compared with the normal side, the involved kidney parenchyma will appear denser (nephrogram). There is a delay in the filling and visualization of the collecting system. Because of the obstruction, the calyces are blunted. If films are taken for a sufficiently long period, the collecting system and ureter will fill to the point where the stone is lodged (Fig. 5). Generally, a retrograde pyelogram is not needed to confirm the diagnosis. The diagnosis of a radiolucent stone can only be made by intravenous or retrograde urography. In these patients, the plain film will be normal, but the delayed excretion and the obstructive changes described above will be seen (Fig. 6).
TRAUMA The degree of hematuria is a poor indicator of the severity of injury to the kidney; severe hematuria may be seen with only minor contusions as well as with massive lacerations. (Text continued on page 211.)
208
P.
RUBEN KOEHLER AND MyO M. KYAW
Figure 4. Intravenous urogram in a patient with sickle cell disease. This illustration shows the radiographic appearance of papillary necrosis. Several small medullary-type cavities (arrows) are seen adjacent to minor calyces. Notice that while the disease involves two of the calyces, the others appear normal. The presence of abnormal calyces adjacent to normal calyces is the rule and not the exception in patients with papillary necrosis.
HEMATURIA
209
Figure 5. A 45 year old patient with a history of urinary tract infection and occasional episodes of microscopic hematuria. The patient recently had an episode of gross hematuria which cleared after one day. A, Scout film taken prior to intravenous urogram; note calcifications over both kidneys. B, Film taken 10 minutes after the injection of contrast medium. The calcification in the right kidney is located within the lower calix (arrow). The calcifications on the left are within the minor calix of the upper calyceal group; a large composite stone almost completely occupies the lower calyceal group (arrow). Had the scout film of the abdomen not been taken, the calcifications could have easily been missed, because their density is almost identical to that of the excreted contrast medium.
210
P.
RUBEN KOEHLER AND MyO M. KYAW
FigurE) 6. A, Scout films of the abdomen show a calcific density (arrow) opposite the third lumbar vertebra in a 45 year old man who developed left flank pain. Urinalysis revealed multiple red cells. B, Intravenous urogram taken 75 minutes after injection. The collecting system on the right is normal. Note the dense nephrogram on the left side. There is only a little contrast medium in the collecting system. The ureter is not filled. This is a characteristic picture of obstruction in the ureter.
HEMATURIA
211
Figure 6 Continued. C, Film taken 3 ' /2 hours after injection. The stone has now moved to the level of the sacrum (arrow). The ureter and collecting system are filled up to that point. Generally, when a nephrogram can be seen (as in B), if films are taken over a sufficiently long period of time, the exact location of the stone can practically always be demonstrated.
Depending on the type of trauma, one can suspect where the injury to the urinary tract occurs. If the trauma involves the abdomen and the patient has hematuria, renal or urethral injury is most likely. If the patient has multiple pelvic fractures, injury to the bladder of the urethra is probable. Renal injuries may be classified according to their severity as concussions, ruptures, lacerations with or without the involvement of calyces and renal pelvis, and tears of the vascular pedicle. These potential injuries are shown schematically in Figure 7. The radiologic work-up depends on the clinical state. A patient who is in shock because of blood loss is generally too ill to undergo prolonged radiologic examination. If the plain film of the abdomen shows loss of the psoas muscle and a poor outline of the kidney, and if the patient's blood pressure and hematocrit are dropping, one should suspect a tear of the renal pedicle; the patient should be sent to surgery immediately. Because of the massive blood loss involved, tear of the vascular pedicle is the most life-threatening type of injury. If the patient's condition is stable, intravenous urography should be performed. Unfortunately, the intravenous urogram is a poor index to the extent of renal damage. On the intravenous urogram one searches for extravasation of contrast medium (Fig. 8). This will occur only if the injury involves the pelvocalyceal system. In a significant number of patients, deep lacerations, even fracture and fragmentation of parts of kidneys, may occur without injury to the pelvocalyceal system. In these patients
212
P.
RUBEN KOEHLER AND MyO M. KYAW
LACERATION OR RUPTURE
Figure 7.
Diagram for the purpose of classifying traumatic injuries to the kidney.
massive blood loss may occur, yet the urogram may appear close to normal. The true extent of injury to the kidney will not be appreciated unless an angiogram is done (Fig. 9). Leakage from the renal artery or its branches, displacement of vessels, or the presence of deep parenchymal clefts, will help to accurately assess the degree of injury. If, in an injured patient, the intravenous urogram is normal or almost normal, no severe blood loss is suspected, and the patient's condition is stable, one may elect to choose a "wait and see" attitude. If the patient's condition improves, no additional studies will be needed, but if signs of infection or chronic blood loss persist, an angiogram should be obtained. If the trauma primarily involves the bony pelvis, the status of the bladder and urethra must be ascertained. Clinically, the most important question is whether the patient can void. In patients who are able to void and have only little or no hematuria, the possibility of major damage to the lower urinary tract is remote. In all instances, the urethra should be examined. The most frequent point of laceration or transection of the urethra is the triangular liagment, where the urethra is relatively fixed to the symphysis. Ideally, examination of the urethra should be done before a catheter is placed in the bladder, since on occasion, the catheter may bridge a complete transection of the urethra. If contrast medium is injected through the urethra without a catheter, the point of injury to the urethra will be found. If the urethra is normal, the catheter can be placed in the bladder and the cystogram done. Most injuries to the bladder are intraperitoneal, but ruptures of the extraperitoneal portions are not rare and must be searched for. The bladder is not often injured during accidents unless it is distended at the time of trauma. Bony fragments, bullets or instruments are common agents causing injuries. Clinical signs of intraperitoneal ruptures are shock and (Text continued on page 217.)
Figure 8. A 42 year old woman who sustained injury to her left flank in a car accident; urinalysis showed gross hematuria. A, Film taken during intravenous urography approximately 5 minutes after injection of contrast medium. The collecting system on the left side is poorly seen. There is an accumulation of contrast medium around the lower pole. B, Arteriogra m done immediately follOwing the intravenous urogram shows a significantly injured left lower pole. There is a deep cleft (between arrows) in the renal parenchyma. Extravasated contrast medium on the intravenous urogram comes from the lacerated lower calix. The tip of the kidney is completely avulsed and the renal capsule (white arrows) is removed from the renal tissue. This illustrates severe injury to the kidney, the degree of which is difficult to evaluate on urography alone. The prognosis in an injury such as this is guarded; in this patient attempts to perform a heminephrectomy were not successful, and the kidney had to be removed.
213
214
P.
RUBEN KOEHLER AND l\1YO
M.
KYAW
Figure 9. This patient was involved in a car accident and sustained injuries to his right flank. Gross hematuria was present. A, Intravenous urogram shows extensive extravasation of contrast medium, which is found around the upper pole of the ,kidney, much of it being subcapsular. Laceration of the renal pelvis or the upper calix or both must be suspected in such circums tances.
HEMATURIA
215
Figure 9 Continued. B, Renal angiography done immediately after urography shows that most of the intrarenal branches are intact, although there is some spasm and poor perfusion of the upper pole. The extensive extravasation is not from the blood vessels, but rather from the pelvocalyceal system (i.e., urine). Based on the angiographic study, it was concluded that the damage was rather minor. The patient was treated conservatively and did well.
Figure 10. This patient sustained severe trauma to the pelvis; note that both pubic and ischial rami are fractured. The patient had gross hematuria. A, A balloon was inserted into the urinary bladder (B) and the bladder filled with contrast medium. Extravasation into the retroperitoneal space is apparent. B, The nature of the retroperitoneal extravasation was better appreciated after the contrast medium was drained from the bladder. The contrast medium, present in the retroperitoneal space, is scattered throughout the injured tissues; the borders are ill-defined. Because the medium is in a confined space it does not change even when the patient's position is changed. This type of distribution of contrast medium is characteristic of its presence in the retroperitoneum. A similar appearance will be seen if a ureter or urethra is injured and the contrast medium leaks into the retroperitoneal or pelvic soft tissues.
216
217
HEMATURIA
Figure 11. Large fungating carcinoma of the bladder. Note the ill-defined irregular right border of the bladder. The tumor extends to the trigonum; the right ureter is partially occluded. The ureter is widened because of the obstruction caused by the tumor (T).
signs of acute peritonitis. Microscopic or macroscopic hematuria is always present. The diagnosis can be made by cystoscopy or cystography. With intraperitoneal ruptures, contrast medium outlining the bowel can be seen. When the laceration is into the retroperitoneal space, a rather characteristic accumulation of contrast medium in the .retroperitoneum is seen (Fig. 10). The contrast will remain after the bladder is emptied.
TUMORS OF THE URINARY TRACT One out of every five patients with hematuria has a tumor. Most of the lesions are in the urinary bladder, and the diagnosis can be best made by cystoscopy. Tumors of the bladder can be demonstrated radiographically (Fig. 11). Tl1ey can be seen on late films taken during intravenous urography or on films taken during the cystogram. The filpls show filling defects and irregularities in the bladder. The extent, and occasionally the depth of invasion, can be demonstrated both by cystography and angiography; however, in most instances cystoscopy and thorough bimanual pelvic examination will suffice in establishing the diagnosis and extent of the disease. Renal masses can frequently be identified by changes in the kidney outline on plain films of the abdomen. However, even on intravenous urography, it is usually not possible to predict the nature of the mass. Deformity of the collecting system and changes in the outline of the kidneys will be seen in renal cell carcinomas and in benign renal cysts. If the tumor is peripheral, it may grow in an eccentric manner so that little or
218
P.
RUBEN KOEHLER AND MyO
M.
KYAW
Figure 12. Intravenous urogram in a patient with a ' single episode of gross painless hematuria. A mass with a calcific rim is noted in the lower pole of the right kidney (between arrows). This patient had a renal cell carcinoma.
no distortion of the internal architecture occurs. Mere displacement of the collecting system on the other hand does not mean that a malignant lesion is present. Single or multiple renal cysts, renal abscesses, as well as malignant tumors, all similarly affect the collecting system, and all can be associated with hematuria. Rim-like calcifications, although more frequently associated with malignant tumors, may be seen with benign cysts; however, stippled and amorphous calcifications are almost always signs of malignancy (Fig. 12). When technically good intravenous urograms are available, little additional information is gained from retrograde pyelography. In practically all instances, the radiologist can differentiate between benign and malignant renal mass lesions. Nephrotomography, angiography and ultrasound, as well as direct percutaneous puncture of the mass, may be done. Currently, our policy in working-up patients with renal masses is to perform an intravenous urogram. This examinagon is followed with ultrasonic scans. If the sc:m indicates the presence of malignant tumor, an angiogram is then performed (Figs. 13 and 14). This is to confirm the diagnosis and to outline the true extent of the lesion. When the ultrasound scan suggests a cystic mass, a percutaneous puncture is performed (Fig. 15); renal cysts will yield a clear yellow fluid, which is studied for the presence of malignant cells and elevation of lactic acid dehydrogenase and fat. If no malignant cells are seen and LDH and fat are low, the diagnosis of benign cyst is practically assured and no further treatment is needed. If the puncture yields bloody fluid or if suspicious cells are seen, an angiogram is done. Percutaneous puncture is a simple, safe and very reliable procedure. There is no evidence that punc-
219
HEMATURIA
o
Figure 13. A, Intravenous urogram in a patient with hematuria. A large mass is present on the upper lateral border of the left kidney (arrows). B, Typical arteriographic findings of renal cell carcinoma. Note the markedly irregular tortuous tumor vessels in the involved portion of the kidney.
220
P.
RUBEN KOEHLER AND MyO
M.
KYAW
Figure 14. Young adult with a history of several episodes of gross painless hematuria. Intravenous urogram was essentially normal. A, Selective right renal angiogram shows typical tumor vessels in the lower part of the right kidney (T). B, Ultrasonic examination was performed. This is a Polaroid print of a transverse scan done 6 cm above the iliac crest with the patient in the prone position. Note the echoes within the tumor (T arrow). The lower group of echoes represents the calyceal system, which is pushed downward. The large dark area in the middle represents the spine (S). Compare the findings of this study with Figure 15, which represents a benign cyst.
HEMATURIA
221
Figure 14 Continued. C, The same tumor studied in the A mode. Note that several spikes are present within the area of the tumor. These represent areas of sound refraction. Whenever such spikes are present within a mass, the diagnosis of a solid tumor must be made.
ture of a malignant tumor will result in any implantation of cells along the needle tract.23 Neoplasms arising in the renal pelvis, calyces and ureter comprise only 5 per cent of renal tumors. Histologically, they are transitional cell carcinomas - the same cell type as tumors of the urinary bladder. Hematuria, gross or microscopic, is the most common sign. Radiographically, these tumors are best demonstrated by intravenous or retrograde urography. They generally do not calcify or form large masses, and thus they cannot be detected on plain films of the abdomen. They grow primarily into the collecting system rather than into renal parenchyma. On intravenous or retrograde urography, the tumors appear as irregular filling defects occupying the renal pelvis or a calyceal group (Fig. 16). Less frequently, they will appear as small round persistent filling defects. Since they are usually associated with hematuria (blood clots in the renal pelvis may have a similar appearance), it is important to examine the patient after the hematuria has subsided to see if a filling defect persists. Because transitional cell carcinomas are poorly vascularized, angiography is far less reliable in their diagnosis than in the diagnosis of renal cell carcinomas. Tumors of the ureters are commonly associated with partial or complete urethral obstruction (Fig. 17). Other mass lesions which may cause hematuria are polycystic kidneys (Fig. 18), arteriovenous malformations (Fig. 19), renal abscesses, and spontaneous bleeding into the kidney, particularly in drug abusers, patients with collagen vascular disease, or patients who are being treated with anticoagulant medication. While the diagnosis of polycystic disease is fairly characteristic on intravenous urography (Fig. 18), the diagnosis of all other mass lesions is usually not characteristic enough on the intravenous urogram to allow a definitive diagnosis, and angiography will be necessary for the work-up (Fig. 19). (Text continued on page 232.)
222
P.
RUBEN KOEHLER AND MyO M. KYAW
Figure 15. A 23 year old man with a history of microscopic hematuria. A, Intravenous urogram shows a large mass in the lower pole of the left kidney (arrows). B, Selective renal arteriogram-arterial phase. Note the sharp demarcation between the normal kidney tissue and the mass. There are no pathological vessels seen.
HEMATURIA
223
Figure 15 Continued. C, On the nephrographic phase, the sharp demarcation between the normally vascular kidney and the avascular mass is clearly seen. This is the typical appearance of a benign cyst. Compare these findings with Figures 13 and 14 which show angiographic findings characteristic of a malignant tumor.
224
P.
RUBEN KOEHLER ANDMyO M. KYAW
Figure 15 Continued. D, Ultrasonic examination. Transverse scan taken 5 cm above the iliac crest with the patient prone. Note the sonolucent area on the left side. The posterior border is sharp, typical of a cyst Cc). The right kidney Ck) is smaller, and few echoes from the normal calyceal system are demonstrated within it. E, Longitudinal ultrasound scan taken 8 cm to the left of the midline. The cyst Cc) adjacent to the kidney Ck) is clearly seen. There are no .echoes within it.
225
HEMATURIA
.
I
•
I
F
,
Figure 15 Continued. F, A-mode scan shows no echoes within the cyst (between arrows). Compare the last three illustrations with the ones presented in Figure 14. It is apparent that the ultrasound characteristics of a benign cyst vary significantly from those of a malignant tumor. G, The cyst is punctured and water-soluble contrast medium is injected through the needle. Note the homogeneous distribution of the contrast medium and the sharp margins of the cyst. Had this been a tumor, the contrast medium would appear irregular with ill-defined borders. Histological examination of the aspirated fluid should be made. The levels of LDH and fat content are assessed ; in a cyst they are low, in a tumor they are high .
226
P.
RUBEN KOEHLER AND MyO M. KYA-W
Figure 16. Transitional cell carcinoma of the kidney. There are filling defects in the upper and mid calyceal groups, as well as in the upper margin of the renal pelvis. This is the characteristic picture of transitional cell carcinoma; however, blood clots, radiolucent stones, and infection may on occasion mimic this picture. A definitive diagnosis can be made if a catheter is placed in the ureter and the collected urine is examined for malignant cells.
HEMATURIA
227
Figure 17. Primary carcinoma of the ureter. The patient first sought medical advice because of left flank pain. Urinalysis demonstrated microscopic hematuria The diagnosis of a renal stone was suspected, but intravenous urography clearly shows an irregular polypoid mass present in the upper ureter. The histologic diagnosis was transitional cell carcinoma.
228
P.
RUBEN KOEHLER AND MyO M. KYAW
Figure 18. A, Intravenous urogram in a patient with polycystic disease. Note the bizarre appearance of the collecting system bilaterally. The calyces are spread and splayed around multiple masses. The kidneys measure 18 cm in length (normal is 12 to 14 cm). This is the typical appearance of polycystic disease. B, Selective renal arteriogram in a patient with polycystic disease. No tumor vessels are present, however, some of the intrarenal branches are splayed around filling defects.
HEMATURIA
229
Figure 18 Continued. C, The typical filling defects of polycystic disease are better seen in the nephrographic phase. The so-called "Swiss cheese" appearance is evident in this illustration.
230
P.
RUBEN KOEHLER AND MyO M. KYAW
Figure 19. Young adult with a history of one episode of painless hematuria. A, Intravenous urogram shows splaying of calyces in the upper and lower calyceal group. The picture is nonspecific, but a tumor was suspected.
HEMATURIA
231
Figure 19 Con tin ued. B, Selective renal arteriogram shows the presence of a congenital arteriovenous malformation.
232
P.
RUBEN KOEHLER AND MyO M. KYAW
SUMMARY In this brief presentation the more common causes of hematuria have been presented. The most frequent causes are cystitis, prostatitis other benign disease. Frequently this diagnosis is only one of exclusion: one must be certain that the hematuria truly originates from these relatively benign diseases. Hematuria should be regarded as a danger signal; the entire urinary tract must be examined carefully to rule out any other abnormality. In 20 per cent of the patients with gross hematuria, malignant tumors have been found; in many instances the tumors can be cured if detected early.
REFERENCES 1. Becker, J. A.: Transitional cell carcinoma of the renal pelvis: Causes of non-visualization on excretory urography. J. Urol., 101 :280--282, 1969. 2. Collins, H. A., and Jacobs, J. K.: Acute arterial injuries due to blunt trauma. J. Bone ]t. Surg., 43A: 193-197, 1961. 3. Dautrebande, J. G., Duckett, G., and Roy, P.: The claw sign of cortical cysts in renal arteriography: A contribution to the differential diagnosis of renal space occupying lesions. J. Canad. Assoc. Radiologists, 18:24-250, 1967. 4. Elkin, M.: Renal vascular shunts. Clin. Radiol., 22:156-170,1971. 5. Ettinger, A., et al.: Importance of selective renal angiography in the diagnosis of polycystic disease. J. Urology, 102:156-161, 1969. 6. Felson, B., and Moskowitz, M.: Renal pseudo-tumors: The regenerated nodule and other lumps, bumps and dromedary humps. Amer. J. Roentgenol., 107:720-729. 7. Ferris, T. F., et al: Recurrent hematuria and focal nephritis. New Eng. J. Med., 276:770775, 1967. 8. Fleming, R. J., and Stern, L. Z.: Multiple intraparenchymal renal aneurysms and polyarteritis nodosa. Radiology, 84:100-103, 1965. 9. Gill, W. M., and Pudvan, W. R.: Arteriographic diagnosis of renal parenchymal diseases. Radiology, 96:81, 1970. 10. Grablowsky, O. M., Weichert, R. F., and Goff, J. B.: Renal artery thrombosis following blunt trauma. Surgery, 67:895-900, 1970. 11. Grabstaldt, H.: Renal cell cancer. n. Diagnosis. N. Y. J. Med., 64:2658-2671,1964. 12. Grabstaldt, H., Whitmore, W. F., and Melamed, M. R.: Renal pelvic tumors. JAMA, 218: 845-854, 1971. 13. Harrow, B. R., Sloane, J. A., and Liebman, N.C.: Roentgenologic demonstration of renal papillary necrosis in sickle-cell trait. New Eng. J. Med., 268:969-976, 1963. 14. Hodson, C. J.: The radiological contribution toward the diagnosis of chronic pyelonephritis. Radiology, 88:857-871, 1967. 15. Jonsson, K.: Renal angiography in patients with hematuria. Amer. J. Roentgenol., 116:758-765,1972. 16. Lang. E. K., et al.: Arteriographic assessment of injury resulting from renal trauma: An analysis of 74 patients. J. Urology, 106:1-8,1971. 17. Lee, L., and Davis, E.: Gross urinary hemorrhage: Symptom, not a disease. JAMA, 153:782-784,1953. 18. Lindvall, N.: Renal papillary necrosis: Roentgenographic study of 155 cases. Acta Radiol., Supp. 192:1-153,1960. 19. Olsson, 0., et al.: Encyclopedia of Urology. Heidelberg: Springer-Verlag, 1962, pp. 165208. 20. Olsson, 0., and Lunderquist, A.: Angiography in renal trauma. Acta Radiol. Diag., 1 :1-21, 1963. 21. Peterson, C., Willerson, J. T., Doppman, J. L., and Decker, J. L.: Polyarteritis nodosa with bilateral renal artery aneurysm and perirenal haematomas: Angiographic and nephrotomographic features. Brit. J. Radiol., 43:62-71,1970. 22. Sullivan, M. J., Smalley, R., and Banowsky, L. H.: Renal artery occlusion secondary to blunt abdominal trauma. J. Trauma, 12:509-515, 1972. 23. Von Schreeb, T., Arner, 0., Skovsted, G., and Wikstad, N.: Renal adenocarcinoma: Is there a risk of spreading tumour cells in diagnostic puncture? Scan. J. Urol. Nephrol., 1 :270276, 1967.
Department of Radiology University of Utah College of Medicine Salt Lake City, Utah 84132
