Abstract
Visible haematuria is a common presentation for investigation. Haematuria should be investigated thoroughly to exclude malignancy. Renal papillary hyperplasia is a rare, benign condition that can cause problematic haematuria. There are no currently management guidelines, as there are only few cases reported. We report a case of NSAID induced visible haematuria due to bilateral renal papillary hyperplasia and managed conservatively.
Keywords: Papillary hyperplasia, Hypertrophy, Haematuria
1. Introduction
Visible haematuria (VH) is a common presentation for investigation which should be investigated thoroughly to exclude malignancy. Renal papillary hyperplasia is a rare, benign condition that can cause problematic haematuria. There are no current management guidelines, as there are only few cases reported.1, 2, 3, 4, 5 We report a case of NSAID induced visible haematuria due to bilateral renal papillary hyperplasia which was managed conservatively.
2. Case
A 58-year-old male was referred to the Urology service for investigation of recurrent exercise-induced visible haematuria. He presented as a fit and healthy, current triathlete with no significant past medical history. He had no family or personal history of coagulopathy, nor was he taking anticoagulants or antiplatelet therapy. The first episode of VH occurred after commencing a non-steroidal anti-inflammatory (NSAID) for osteoarthritis. Haematuria was noticeably worse with Naproxen than Celecoxib.
Urine analysis revealed haematuria (>100 red blood cells) without other abnormal values. Urine cytology was negative for malignant and abnormal cells. Imaging studies included a normal appearing renal ultrasound and a CT ureterogram showing no filling defects of note or other causes of haematuria. The patient underwent a flexible cystoscopy that revealed no lower urinary tract source of bleeding. However, haematuria was seen effluxing from the left ureteric orifice. Subsequent cystoscopy, left retrograde pyelogram (RGPG) and ureteroscopy was performed. The RGPG revealed each renal calyx contained prominent protuberant papillae and nil other findings (Fig. 1). On ureteroscopy, the patient was found to possess an inflamed renal pelvis with each calyx containing prominent and highly vascular renal papillae which appeared not typical of urothelial cancer (Fig. 2). Given the consistent appearance of the papillae throughout both kidneys, lack of risk factors for urothelial cancer and negative cytology, no biopsy was performed given the risk of bleeding. A RGPG was performed on the contralateral side to investigate for similar appearances that would support the presence of bilateral prominent renal papillae.
Fig. 1.
Retrograde pyelography showing prominent papillae in all calyces, bilaterally.
Fig. 2.
Hypertrophied papilla of the left upper, mid, and lower pole calyces.
Subsequent discussion by a multidisciplinary team recommended conservative management with cessation of his NSAIDs and trial of tranexamic acid 1000mg, twice a day.
Surgical treatment (e.g., Holmium: YAG laser ablation) was discussed with the patient, but a shared decision was made for conservative management. After a 3 month follow up, the patient reported complete resolution of visible haematuria.
3. Discussion
Bilateral renal papillary hyperplasia or hypertrophy is a rare pathology due to its asymptomatic nature. A small number of cases have been reported of haematuria caused by papillary hyperplasia. 8 patients have been identified to have symptomatic renal papillary hyperplasia (6 females and 2 males between the ages of 9 months and 32 years age). Lauret et al. (1956) and Whitaker (1969) described two cases of renal papillary hyperplasia diagnosed on histology from by radical nephrectomy after suspecting malignancy, a 9-month-old female with recurrent infections and 21-year-old male with transient visible haematuria.2,3 Moonen (1961) described two cases identified by partial nephrectomy in a 11-year-old male and 25-year-old female that both presented with flank pain4. In more contemporary series, diagnosis was made through less radical methods such as biopsy and flexible ureteroscopy. Most patients presented with flank pain, visible and non-visible haematuria. Three reported cases suggested an association with oral-contraceptive pills, however no other significant associations have been made.
Earlier years supported radical surgical intervention to rule out underlying malignancy. More recently, Beltagy (2020) described endoscopic management using Holmium: YAG laser ablation in 3 cases with complete resolution of symptoms.1 Heißleretal (2018) reports the only other case managed conservatively, in a patient who had non-visible haematuria without other symptoms.5
There is a lack of guidelines and evidence regarding the aetiology, diagnosis, and management of symptomatic bilateral renal papillary hyperplasia. Papillary hyperplasia is considered a benign condition that needs to be distinguished from upper tract urothelial malignancies. Histologically, papillary hyperplasia can be seen with an increased number of cells of the mucosal transitional cell epithelium without signs of malignancy. Investigation with urine cytology, CT ureterogram, and flexible ureteroscopy is required to exclude sinister causes such as upper tract urothelial cancer. In our case, we identified the use of NSAIDs as contributing to haematuria, with cessation proving effective. The use of tranexamic acid, an antifibrinolytic, can also assist with clot stabilisation and prevention of further bleeding.
4. Conclusion
We describe a case at the age of 58, with bilateral papillary hyperplasia, presenting as non-steroidal anti-inflammatory induced haematuria managed non-surgically. In cases of diagnostic dilemma, endoscopic biopsy can be used. With persistent symptoms, the use of Holmium: YAG laser ablation has been shown to be beneficial.
Consent
Written informed consent was obtained from the patient for publication of this case report and accompanying images.
Author statement
MC: Data curation; Writing – original draft; Writing – review & editing, MK: Writing – review & editing; Supervision, KM: Writing – review & editing; Supervision.
Declaration of competing interest
The authors declare that they have no conflicts of interest.
Acknowledgements
Nil.
References
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