BMJ Best Practice

病因学

Visible (gross) haematuria can originate from any part of the urinary system. Anatomically, the urinary system is divided into the upper tract, which includes the kidneys and ureters, and the lower tract, which includes the bladder and urethra. Localising the source of bleeding is a key step in determining the aetiology of haematuria.[7]

Visible haematuria can be caused by infection, malignancy, trauma, stones, structural abnormalities, and kidney disease. Coagulopathy caused by clotting disorders or anticoagulation can induce or exacerbate bleeding from underlying urinary tract lesions. Nephrotoxic medications can cause kidney inflammation and renal papillary necrosis, whereas other medications such as cyclophosphamide can cause bleeding from the bladder mucosa. Instrumentation of the urinary bladder by endoscopes and catheters can cause traumatic bleeding that is generally self-limiting. 

良性血尿可见于运动性血尿和临床意义不明的一种特发性血尿--腰痛血尿综合征。

Visible haematuria should always be distinguished from pseudohaematuria, where blood originating from a non-urinary-tract source, or discolouration of the urine by non-heme compounds, gives the appearance of haematuria.

感染

  • 尿路感染和肾盂肾炎是非常常见的肉眼血尿病因，经常伴有尿频、尿痛症状。尿液分析可发现白细胞、亚硝酸盐或白细胞酯酶。

  • Genitourinary tuberculosis may present with haematuria and leukocytes in the absence of bacteria (sterile pyuria).

恶性肿瘤

血尿可能是泌尿生殖系恶性肿瘤的唯一症状。在 60 岁以上的男性中，肉眼血尿对识别泌尿系恶性肿瘤的阳性预测值为 22.1%，而在同龄女性中为 8.3%。[6]

  • Urothelial carcinoma is the most common form of urological malignancy, accounting for 90% of bladder cancers. Urothelial carcinoma can occur anywhere along the urinary tract and typically presents as painless haematuria.[8]

  • Squamous cell carcinoma and adenocarcinoma are rare types of bladder cancer.

  • 肾细胞癌和肾脏转移肿瘤也会引起血尿，可伴有或不伴有侧腹痛。

  • 前列腺癌可表现为间歇性肉眼血尿。[6]

  • 阴茎癌是皮肤鳞状细胞癌，但如果侵犯尿道或血管可引起肉眼血尿。

外伤

  • 肾脏、输尿管、膀胱或尿道穿透伤或钝性伤通常表现为肉眼血尿。

  • 80%-90% 患者的肾脏损伤是由侧腹部或腹部钝性伤所致。[9] 其它病因包括：枪伤和刀伤所致穿透伤，机动车事故所致减速伤以及下肋骨骨折所致撕裂伤。

  • 输尿管创伤罕见，不过可见于穿透伤、钝性伤或医源性损伤等情况下。输尿管医源性离断可发生于复杂的结直肠手术和妇科手术过程中。相比输尿管横断和结扎，内镜检查如输尿管镜检查更可能导致血尿。尿路经皮入路、肾脏活检或输尿管留置支架也可引起创伤性出血。

  • 膀胱创伤可引起肉眼血尿，通常见于机动车撞车事故或骨盆骨折。8%-10% 患者的膀胱破裂与骨盆骨折有关。[10]

  • 尿道损伤，多见于男性，表现为尿道口可见的血液。可能伴有不能排尿或初始血尿或终末血尿。

  • 对于骨盆骨折及尿道口可见血液的男性，在行逆行尿道造影排除尿道断裂前，禁止留置导尿管。

  • 女性尿道损伤很少见，因为女性尿道短且活动度大，但在骨盆骨折的情况下也可能发生。[11]

泌尿系结石病

  • 尿石症是由晶体沉积于肾脏或膀胱所致，通常引起间歇性疼痛，疼痛可能严重，但有一些患者无症状。高达 85% 的患者可见镜下血尿，[9] 但是肉眼血尿很少见。

结构异常

  • Benign prostatic hyperplasia (BPH) predisposes men to visible haematuria and clot formation,[12][13] possibly due to increased density of microscopic vessels in the prostate.

  • 经导尿减压解除急性尿潴留后，2% 到 16% 的患者可发生肉眼血尿（减压性血尿 [haematuria ex vacuo]）。[14]

  • 囊性肾病（例如多囊肾、髓质海绵肾和肾髓质囊性病）可能导致肉眼血尿。

  • Vascular malformations and arteriovenous fistulas may spontaneously bleed into the urinary tract. Ureteroarterial fistula is a rare complication of urological surgery.[15]

  • 可由肾细胞癌或肾病综合征导致的肾静脉血栓通常表现为侧腹痛和肉眼血尿。

肾内科疾病

Pathology involving the renal parenchyma and glomeruli may present as haematuria that is characterised by dysmorphic red cells and casts of red or white blood cells. Significant proteinuria may be a prominent feature of these disorders, and renal function may be compromised. Referral to a nephrologist is important for the management of this broad category of disorders. A nephrology consultation should be obtained for patients with renal failure, heavy proteinuria (>3 g/day), or severe hypertension, as prompt treatment or a renal biopsy may be necessary.[16]

  • 良性家族性血尿是由导致基底膜变薄的遗传缺陷所致。

  • Alport 综合征是 IV 型胶原异常导致的一种遗传性肾小球基底膜疾病，可能进展至肾衰竭。表现为蛋白尿、血尿、耳聋和高血压。

  • 肾小球肾炎（例如 IgA 肾病、感染后肾小球肾炎、膜增殖性肾小球肾炎、急进性肾小球肾炎以及系统性红斑狼疮 [systemic lupus erythematosus, SLE]）是一系列导致肾小球炎症的原发性和继发性免疫介导疾病，需要由肾内科进行会诊。此类疾病患者也会不同程度地出现蛋白尿和肾衰竭。

  • 肾小球病变可以单独存在，也可以是系统性自身免疫过程的一部分，如系统性红斑狼疮。

血液学

  • 镰状细胞性贫血可出现血尿、尿痛、多尿等泌尿道症状，同时尿液分析为等渗尿（尿液未经肾脏浓缩）。

  • 凝血障碍患者可出现胃肠道和泌尿道等多部位出血。

  • Patients on anticoagulation therapy may have visible haematuria, but urinary tract bleeding (even in cases of supertherapeutic anticoagulation) almost always represents an exacerbation of an underlying disease process or urinary tract lesion.[17]

妇科

  • Placenta percreta is a form of invasive placental implantation where the myometrium of the uterus is penetrated. Between 5% and 7% of patients show this depth of invasion, and in rare cases it extends into the bladder to cause severe haemorrhage and haemodynamic instability.[18] 当妊娠期出现肉眼血尿，尤其在有前置胎盘病史或剖宫产既往史时，应怀疑胎盘植入。

  • 异位子宫内膜组织累及输尿管或膀胱的子宫内膜异位症可能表现为侧腹痛、尿痛和周期性血尿。

医源性

  • 通过内镜或经皮入路进行尿道仪器检查可引起自限性出血。

  • 导尿管、留置输尿管支架或肾盂引流管可引起尿路出血。

  • 盆腔癌症外放射治疗可引起放射性膀胱炎，其严重程度不等，可表现为镜下血尿、尿频、严重出血、尿失禁甚至膀胱坏死。

  • Prostate brachytherapy can lead to acute or late haematuria.[19]

  • 可诱发肾小管坏死或间质性肾炎的药物可导致血尿。肾毒性药物包括：氨基糖苷类药物、环孢素和一些化疗药物。青霉素、磺胺类药物、非甾体抗炎药可诱发间质性肾炎。

  • 环磷酰胺是出血性膀胱炎的重要病因，可导致严重出血。[20]

  • Anticoagulation with heparin, warfarin, and low-molecular-weight heparin, even at supertherapeutic doses, generally does not cause haematuria unless there is underlying pathology. Further evaluation must be undertaken to rule out important causes of bleeding, such as malignancy.[17]

特发性

  • 运动性血尿是一种见于运动员和运动活跃人群的良性自限性疾病。

  • 腰痛血尿综合征是一种不明病因的良性实体病变，主要症状为腰痛和间歇性血尿。主要发生于育龄女性。关于该综合征作为实体疾病诊断的临床意义尚存在争议。

假性血尿

  • 周期性假性血尿可发生于经期。

  • 某些食物和药物可以使尿液变色，与血尿相似。药物包括非那吡啶、利福平、苯妥英、左旋多巴、甲基多巴和奎宁。食用甜菜、黑莓和大黄也可以使尿液变色。

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