症状学12.尿频血尿课件

Symptomsandsignsofthekidneyandurinarysystem

第一页，共三十六页。Slide2Symptomsandsignsofthekidneyandurinarysystem

Alterationsinurinecomposition(haematuria,proteinuria,bacteriua,leucocyturia,calculi)DisordersofMicturation(frequency,urgency,dysuria,

incontinence,

retention)DisordersofUrinevolume(oliguria,anuria,polyuria)Loindullpain(pyelonephritis,obstruction),renalcolic(acuteobstruction)Oedema(hypoalbuminaemia,saltandwaterretention)

SymptomsofUraemia(nausea,vomiting,lethargy)第二页，共三十六页。血 尿

Haematuria第三页，共三十六页。Slide4HematuriaDefinitionCausesLocalizationandpathogenesisAssociatedsymptomsEvaluationofHematuriaCasestudy第四页，共三十六页。Slide5DefinitionofhematuriaMicroscopicevaluationofurinarysediment:freshlyvoided(10ml),centrifuged(1500rpmfor5min)

urinesediment:RBC3/HPonatleast2out3collectedspecimensDipsticktest：freehemoglobin&myoglobin,needconfirmationTwoTypesofHematuriaGrosshematuria

(>1ml/l):brightred,tea-coloredbrownorcocacolaMicroscopichematuria:theurineisclear,RBCcanbeseenunderamicroscopeortestedinalab(byflowcytometry).第五页，共三十六页。Slide6Pseudohematuria

MenstruatingfemalePigmenturia:presenceofcoloredsubstanceintheurine.Endogenous:myoglobin(breakdownofmuscle;pink,red,brownorblack)HemoglobulinExogenousDrugs:phenytoin(redurine),rifampin(yellow-orangetored),metronidazole,nitrofurantoin(brown),warfain…Foods:beetroots(red),berries,rhubarb(yellowtobrownorred)第六页，共三十六页。Slide7CausesofHematuria

Kidneyandurinarytractdiseases

Glomerulonephritis(GN):IgAnephropathy,MembranoproliferativeGN,CrescenticGN,FSGS,Renalvasculitis.Lupusnephritis,Schonlein-Henochnephritis,acutePoststreptococcalGNInfection:Pyelonephritis,Cystitis,Urethritis,prostatitis,TBStone:kidney,Ureter,bladder,urethraTumors:kidney,Ureter,bladder,prostateHereditarydisease:Alpert’ssyndrome,Thinglomerularbasementmembranenephropathy,PolycystickidneydiseaseRenalvesseldiseases:

Arterialemboliorthrombosis,Renalveinthrombosis,Arterialorvenousmalformation

Others:Interstitialnephritis,papillarynecrosis,trauma

第七页，共三十六页。Slide8CausesofHematuria

Systemicdiseasessystemiccoagulationdisorders:TTP,plateletdefect,coagulationproteindeficiency,therapeuticanticoagulationInfectiousdiseases:SBE,severeinfectiousdiseaseMalignantHTN,DN,AmyloidosisPhysicalinjuryandchemicaltoxicationvigorousexercise:marathonrunningNutcrackersyndromeIdiopathichematuria第八页，共三十六页。Slide9LocalizationofHematuriaGlomerularHematuriaFromtherenalparenchymaNon-glomerularHematuriaFromtherenalpelvis,ureters,bladder,orurethra(urinarytractbleeding)第九页，共三十六页。Slide10GlomerularHematuriaGNortubulointerstitialnephritisPathogenesisSmallbreaksintheGBMRuptureoftubularbasementmembraneDysmorphic

hematuria（>80%)Fragmented,distortedRBC,knoblikeprojections(passingthroughgapsofGBM)Thedegreeofdysmorphismmaybeinfluencedbytheurineosmolality,PHinthetubuleandthetimefrompassageofurineOtherclues:

significantproteinuria(>1g/d),redcellcasts,hypertensionandedema第十页，共三十六页。Slide11Non-glomerularHematuria

Infection,tumor,stone,traumaorarteriovenousmalformationsDuetoinflammationofmucosa,disruptionofsmallvesselsanderosionofurinarytractUniformbioconcaveshapeisomorphic(>80%normomorphic)Otherclinicalclues:loinpain,superpubicpain,passageofclots(notbeencounteredinpatientswithglomerulardisease)第十一页，共三十六页。DetectionMethodflowcytometry:automatedmethoduncentrifugeduninesamplesScreenlargenumbersofsamplesinashorttimesamplesofparticularcomplexityforwhichamicroscopicanalysisispreferablephasecontrastmicroscopy:observerdependent第十二页，共三十六页。Three-glasstest

grosshematuriawithnormomorphicerythrocyturia,

Inthefirst10-15mlurine:theurethraInthefinal10-30mlurine:asmallhemorrhagefromthetrigoneregionofthebladderInallthreesamples:thekidneyorprofusebleedingfromthebladderSlide13第十三页，共三十六页。Slide14AssociatedsymptomsPain:loindullpain(kidneystone),acutecolic(kidney,ureterstone)Frequency,Urgencyanddysuria:cystitis,urethritis,pyelonephritis,prostatitis,TB,tumorAbdomenalmass:renaltumor,polycystickidneydiseaseBleedingtendency:hematologicdisordersFever:acutepyelonephritis,TBHTN,edema,proteinuria:GNChyluria(whitemilkyurine):

filariasis,TB,tumorAsymptomic:IgAnephropathy,TBMnephropathy,tumor第十四页，共三十六页。Slide15HistorytakingRuleoutpseudohematuria(drug,food,menstruation)PatternofhematuriaBleedingofotherorgans:coagulationdisturbancePasthistoryofthekidney,urinarytractandprostate:HTN,proteinuria,edema,renaldysfunctionFrequency,UrgencyanddysuriaHistoryofdrugingestion:analgesics,antibiotics,anticoaulantsvigorousexercise,urethralcatheterizationFamilyhistoryofrenaldisease,hematuria,deafnessandpolycystickidneydisease

第十五页，共三十六页。Slide16EvaluationofHematuria

HistoryandphysicalexamExcludepseudohematuria,vigorousexerciseLabtests:urinalysis,phasecontrastmicroscopyandotherbloodtestsNephrologicorUrologicevaluationSpecialexaminationsUltrasoundUrineculture,UrinecytologyIntravenouspyelogram(IVP)CT/CTU,MRI,Angiography(arteriovenousmalformation),RadionuclidescansCystoscopyandretrogradepyelogramsRenalbiopsyFollow-upsubtleglomerularortubulointerstitialdiseasesmallarteriovenousmalformations,smallstone第十六页，共三十六页。Slide17病例(bìnglì)一男性，16岁发热、咽痛、流涕2天后出现肉眼血尿(xuèniào)尿常规：RBC250/l进一步检查：尿沉渣镜检：RBC满视野，100％异型第十七页，共三十六页。Slide18血尿与全身疾病(jíbìng)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10－14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。第十八页，共三十六页。Slide19病例(bìnglì)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(kāishǐ)血液透析治疗。伴耳聋一个舅舅、2个堂兄均为尿毒症诊断(zhěnduàn)AlportSyndrome(XD)第十九页，共三十六页。Slide20病例(bìnglì)三女性15岁，体型偏瘦肉眼血尿，反复发作，多在运动后出现(chūxiàn)尿沉渣镜检：RBC满视野，90％正常形态第二十页，共三十六页。Slide21双肾静脉彩超：左肾静脉近肾门处内径(nèijìnɡ)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(nèijìnɡ)变细。诊断：胡桃夹现象第二十一页，共三十六页。尿频、尿急、尿痛

Frequentmicturition,urgentmicturitionandpainonmicturition

(symptomofbladderirritation)协和医院肾内科李明喜第二十二页，共三十六页。Slide23尿频、尿急、尿痛定义、分类(fēnlèi)机制常见疾病病例讨论第二十三页，共三十六页。Slide24定义(dìngyì)Frequency排尿次数增多。正常成人白天排尿3－5次，夜间(yèjiān)排尿0－2次。每次尿量200—400ml。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第二十四页，共三十六页。Slide25Mechanismsoffrequency炎症性刺激：膀胱(pángguāng)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。第二十五页，共三十六页。Slide26UrinaryFrequency–classificationbycauses

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(zǐgōng)(如妊娠)压迫亦常引起尿频。神经源性膀胱。第二十六页，共三十六页。MechanismsofOdynuria

炎症的膀胱自主或不自主的收缩、痉挛(jìnɡluán)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Slide27第二十七页，共三十六页。Slide28CausesofOdynuria

膀胱、尿道感染：细菌(TB)、支原体、病毒(bìngdú)、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：Reiter’syndrome、Behcet’syndrome、Crohn’disease膀胱肿瘤第二十八页，共三十六页。Slide29Urinaryurgency有尿痛见于泌尿道炎症。特别是膀胱三角区粘膜发炎，小量尿液充盈，即可刺激发生尿急，尿痛。粘膜无重要病变，但尿成分发生明显的变化，如感染性尿液，较强的酸碱度变化，对粘膜都有较强的刺激，膀胱结石或异物刺激无尿痛由于神经性因素，致使排尿(páiniào)反射不正常。第二十九页，共三十六页。Slide30

伴随(bànsuí)症状伴发热、脓尿见于尿路化脓性感染伴血尿见于感染（TB）、膀胱肿瘤、结石中年(zhōngnián)男性以上尿频伴进行性排尿困难，见于前列腺增生伴神经系统疾病，见于神经源性膀胱第三十页，共三十六