hey everyone this is dr laura herbert and this presentation is on protein urea and hematuria and even though this presentation is in the acute genital urinary problems in males this lecture can be applied to both men and women protein urea is a common finding on routine urinalysis even a small amount warrants further evaluation because it's a sign of early renal disease about 15 kilograms of protein is filtered through the kidneys every day but only less than 150 milligrams is excreted protein urea is any amount greater than 150 milligrams a day and is the hallmark of renal disease microalbuminuria is a very early sign with 30 to 150 milligrams a day of protein being excreted and you may see this in patients with diabetes or hypertension macro albuminuria is a term used to describe greater than 300 milligrams a day and it can be transient or persistent there are many different causes of protein urea that are listed here in the box this box is 130.1 from your botano text excretion is affected by three factors either glomerular capillary wall weakness which allows albumin to filter through and it's the most common type of persistent protein area proximal tubular cells malfunction and the cells no longer reabsorb the protein or low molecular weight proteins overwhelm the tubular cells and they're unable to reabsorb the protein found in young healthy adults related to prolonged exercise patients with diabetes who are seriously ill with nephrotic syndrome or who have diabetic nephropathy or in pregnancy but if it's less than 24 weeks we consider the cause to be glomerulonephritis and if it's greater than 24 weeks that's a sign of preeclampsia when you discover protein urea you must get a thorough history so you should ask about acute or chronic illness surgeries diagnostic procedures that required contrast dye urinary symptoms rule out a uti a cause of transient proteinuria risk for hiv recent medications including over-the-counter and herbal family history of diabetes or renal disease and recent physical activity and here is a list of diagnostics that you may want to order a urine dipstick with one plus or greater on two or more occasions requires follow-up and there will be many urine and blood tests to order and this only lists some of them your butaro textbook provides a decision tree in figure 130.1 that's very helpful management of protein urea depends on the cause you will want to stop any medication contributing to protein urea you would want to start an ace inhibitor or arb due to their renal protective actions we also want tight control of glucose lipids and blood pressure and consider a sodium and protein restricted diet in some patients hematuria is another common finding on routine urinalysis it's defined as three or more blood cells on microscopic evaluation hematuria can be transient or persistent transient is only present once whereas persistent is present on two or more occasions and it's the most common sign of bladder cancer there are many different causes of hematuria that are listed here in the box this box is 130.2 from your botano text rates vary with gender and age with older males at highest risk of prevalence there are many causes it can occur with local disease confined to the renal system or it can be evidence of systemic disease hematuria combined with protein urea is suggestive of glomerular or interstitial nephritis when you discover hematuria you must get a thorough history so you should consider urinary patterns and color of urine you should consider age you should also consider gender men are more likely to have malignant disease women are more likely to have acute cystitis or urethritis you should consider physical activity because 13 of long distance runners have hematuria you should consider presence of pain as an indicator colicky flank pain suggests its origin is in the ureter you should also consider timing if the if the blood tends to be present at the beginning of urination or at the end of urination then you should be suspicious of prostatic or urethral causes ask about recent illness of sore throat or skin infection because it could clue you into possible post-infection glomerulonephritis especially if the patient has hematuria plus proteinuria accompanied by edema and hypertension this is likely a transient decrease in renal function ask about a past medical history of utis or renal stones consider recent medications including over-the-counter and herbal and consider the patient's smoking status because cigarette use increases the risk of bladder cancer and then finally you want to ask about sexual history and the risk of sexually transmitted infections including hiv your physical exam will include a full comprehensive exam plus for women you would do a pelvic exam and examine the urethra and vagina for local causes for men you would also do a genital and rectal exam is the patient uncircumcised retract the foreskin for local causes and then you would also do a prostate exam at a minimum you want to get a urinalysis urine cns and urine for cytology you would obtain an in and out cath if a clean catch urine specimen is not reliable plus you would order blood work to include a cbc with diff and basic metabolic panel for a bun and creatinine your butaro textbook provides a decision tree in figure 130.2 that divides evaluation into painful or painless hematuria that's very helpful painful hematuria guides you to consider infection or stones painless hematuria guides you to consider a broader differential if you find a mass on ultrasound you will want to get a ct if the ultrasound is negative you may want to send to a urologist to do a cystoscopy to look at bladder tissue management of hematuria depends on the cause because management will be driven by the underlying condition not the presence of hematuria isolated or transient hematuria doesn't require referral to a urologist especially if the cause is related to an infection that you can identify and treat red flags and indicators that the patient requires urgent referral or hospitalization includes gross hematuria severe flank pain unstable vital signs evidence of urologic obstruction meaning the patient has bladder distension or anuria or acute renal failure all right if you have any questions please post them to the discussion board