课件：症状学尿频血尿.ppt

Symptoms and signs of the kidney and urinary system,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),血 尿,Haematuria,Slide 4,Hematuria,Definition Causes Localization and pathogenesis Associated symptoms Evaluation of Hematuria Case study,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 specimens Dipstick test ：free hemoglobin & myoglobin, need confirmation Two Types of Hematuria Gross hematuria ( 1ml/l): bright red, tea-colored brown or coca cola Microscopic hematuria: the urine is clear, RBC can be seen under a microscope or tested in a lab (by flow cytometry).,Slide 6,Pseudohematuria,Menstruating female Pigmenturia: presence of colored substance in the urine. Endogenous: myoglobin (breakdown of muscle; pink,red,brown or black) Hemoglobulin Exogenous Drugs: phenytoin (red urine), rifampin (yellow-orange to red), metronidazole, nitrofurantoin (brown), warfain Foods: beetroots (red), berries, rhubarb (yellow to brown or red),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 GN Infection: Pyelonephritis, Cystitis, Urethritis, prostatitis, TB Stone: kidney, Ureter, bladder, urethra Tumors: kidney, Ureter, bladder, prostate Hereditary disease: Alperts syndrome, Thin glomerular basement membrane nephropathy, Polycystic kidney disease Renal vessel diseases: Arterial emboli or thrombosis, Renal vein thrombosis, Arterial or venous malformation Others: Interstitial nephritis, papillary necrosis, trauma,Slide 8,Causes of Hematuria,Systemic diseases systemic coagulation disorders: TTP,platelet defect, coagulation protein deficiency, therapeutic anticoagulation Infectious diseases: SBE, severe infectious disease Malignant HTN, DN, Amyloidosis Physical injury and chemical toxication vigorous exercise: marathon running Nut cracker syndrome Idiopathic hematuria,Slide 9,Localization of Hematuria,Glomerular Hematuria From the renal parenchyma Non-glomerular Hematuria From the renal pelvis, ureters, bladder, or urethra (urinary tract bleeding),Slide 10,Glomerular Hematuria,GN or tubulointerstitial nephritis Pathogenesis Small breaks in the GBM Rupture of tubular basement membrane Dysmorphic 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 urine Other clues: significant proteinuria(1g/d), red cell casts, hypertension and edema,Slide 11,Non-glomerular Hematuria,Infection, tumor, stone, trauma or arteriovenous malformations Due to inflammation of mucosa, disruption of small vessels and erosion of urinary tract Uniform bioconcave shape isomorphic (80% normomorphic ) Other clinical clues: loin pain, superpubic pain, passage of clots (not be encountered in patients with glomerular disease),Detection Method,flow cytometry: automated method uncentrifuged unine samples Screen large numbers of samples in a short time samples of particular complexity for which a microscopic analysis is preferable phase contrast microscopy: observer dependent,Three-glass test,gross hematuria with normomorphic erythrocyturia, In the first 10-15ml urine: the urethra In the final 10-30ml urine: a small hemorrhage from the trigone region of the bladder In all three samples: the kidney or profuse bleeding from the bladder,Slide 13,Slide 14,Associated symptoms,Pain: loin dull pain (kidney stone), acute colic (kidney, ureter stone) Frequency, Urgency and dysuria: cystitis, urethritis, pyelonephritis, prostatitis, TB, tumor Abdomenal mass: renal tumor, polycystic kidney disease Bleeding tendency: hematologic disorders Fever: acute pyelonephritis, TB HTN, edema, proteinuria: GN Chyluria (white milky urine): filariasis, TB, tumor Asymptomic: IgA nephropathy, TBM nephropathy, tumor,Slide 15,History taking,Rule out pseudohematuria (drug, food,menstruation) Pattern of hematuria Bleeding of other organs: coagulation disturbance Past history of the kidney, urinary tract and prostate: HTN, proteinuria, edema, renal dysfunction Frequency, Urgency and dysuria History of drug ingestion: analgesics, antibiotics, anticoaulants vigorous exercise, urethral catheterization Family history of renal disease, hematuria, deafness and polycystic kidney disease,Slide 16,Evaluation of Hematuria,History and physical exam Exclude pseudohematuria, vigorous exercise Lab tests: urinalysis, phase contrast microscopy and other blood tests Nephrologic or Urologic evaluation Special examinations Ultrasound Urine culture, Urine cytology Intravenous pyelogram (IVP) CT/CTU, MRI, Angiography (arteriovenous malformation), Radionuclide scans Cystoscopy and retrograde pyelograms Renal biopsy Follow-up subtle glomerular or tubulointerstitial disease small arteriovenous malformations, small stone,Slide 17,病例一,男性，16岁 发热、咽痛、流涕 2天后出现肉眼血尿 尿常规：RBC 250/l 进一步检查： 尿沉渣镜检：RBC满视野，100异型,Slide 18,血尿与全身疾病及呼吸道感染的时间关系 急性链球菌感染后肾小球肾炎： 感染后1014天出现血尿 IgA肾病： 上呼吸道症状与血尿几乎同时发生， 一般不超过3天。,2019/8/6,19,可编辑,Slide 20,病例二,男性，22岁 因乏力、食欲不振就诊，发现血尿、蛋白尿、肾功能差，诊为“尿毒症”，开始血液透析治疗。 伴耳聋 一个舅舅、2个堂兄均为尿毒症,诊断,Alport Syndrome (XD),Slide 21,病例三,女性 15岁，体型偏瘦 肉眼血尿，反复发作，多在运动后出现 尿沉渣镜检：RBC满视野，90正常形态,Slide 22,双肾静脉彩超：左肾静脉近肾门处内径增宽，腹主动脉与肠系膜上动脉夹角处左肾静脉管腔受压，内径变细。 诊断： 胡桃夹现象,尿频、尿急、尿痛 Frequent micturition, urgent micturition and pain on micturition (symptom of bladder irritation),协和医院 肾内科 李明喜,Slide 24,尿频、尿急、尿痛,定义、分类 机制 常见疾病 病例讨论,Slide 25,定义,Frequency 排尿次数增多。正常成人白天排尿35次，夜间排尿02次。 每次尿量200400ml。 Urgency 尿意一来即要排尿的感觉，不能控制, 每次尿量均较正常少。 Odynuria 排尿时或刚结束尿道、耻骨上区、会阴疼痛感，主要为刺痛或灼痛。 三者合称膀胱刺激征或尿路刺激征,Slide 26,Mechanisms of frequency,炎症性刺激：膀胱内有炎症时、神经感受阈限降低，尿意中枢一直处于兴奋状态，导致尿频。 膀胱容量减小：包括膀胱内占位性病变及挛缩膀胱，引起每次排尿量减少，排尿次数增多，可不伴尿急和尿痛。 神经系统病变：膀胱高反应性而出现尿频，可伴尿急，但无尿痛。 下尿路梗阻：排尿困难，排尿费力。,Slide 27,Urinary Frequency classification by causes,生理性尿频：饮水过多、精神紧张、气侯变化等可以改变排尿的频率。 病理性尿频： 每次尿量正常，全日总尿量增多：糖尿病、尿崩症、ARF恢复期 每次尿量减少，全日总尿量正常或减少： 肾脏疾病：肾结核、肾盂肾炎、多囊肾等； 膀胱及尿道疾病：急性膀胱炎、尿道炎、前列腺增生症。膀胱结石和膀胱结核所致的挛缩膀胱、膀胱肿瘤、尿道狭窄等。 继发于泌尿系邻近器官疾患：盆腔及会阴邻近器官炎症、肿块，盆腔内肿瘤、增大的子宫(如妊娠)压迫亦常引起尿频。 神经源性膀胱。,Mechanisms of Odynuria,炎症的膀胱自主或不自主的收缩、痉挛 尿液流经发炎的尿道 尿路阻塞或尿道异物：从膀胱颈至外尿道口任何部位的阻塞均可造成尿痛，可不伴有炎症性疾病 重度血尿或尿液酸度过高偶尔也可产生尿痛,Slide 28,Slide 29,Causes of Odynuria,膀胱、尿道感染：细菌(TB)、支原体、病毒、寄生虫 前列腺疾病（炎症、增生） 阴道炎：细菌、真菌、原虫、病毒 女性雌激素缺乏 间质性膀胱炎 化学刺激：清洁剂 尿路梗阻 系统性疾病：Reit