Hematuria – presence of >3 RBCs /hpf on urine microscopy
- In adults, suspect urologic malignancy until proven otherwise
- All patients, except young females with acute bacterial hemorrhagic cystitis, should have urologic evaluation
- Most common cause of gross hematuria in patients > 50 yrs = bladder cancer
Causes of hematuria
- Prerenal
- Coagulopathy (hemophilia, ITP)
- Anticoagulation
- Collagen vascular disease (SLE, scleroderma)
- Sickle cell disease
- Renal
- Glomerular
- Gomerulonephritis
- Lupus nephritis
- Benign familial hematuria
- Alport’s syndrome
- Vascular abnormalities
- Nonglomerular
- Pyelonephritis
- Granulomatous disease (TB, cryptococcosis)
- Xanthogranulomatous pyelonephritis
- Interstitial nephritis
- Papillary necrosis
- Neoplasm (RCC)
- Glomerular
- Postrenal
- Calculus
- Ureteritis
- Cystitis
- Prostatitis
- BPH
- Epididymitis
- Urethritis
- Neoplasm (TCC)
- False
- Vaginal bleeding
- Recent circumcision
- Factitious
- Pigmenturia (myoglobinuria, hemoglobinuria, porphyria; foods – beets, blackberries; drugs – rifampin, quinine sulphate)
Most common causes by age group:
AGE CAUSE
0 -20 glomerulonephritis, UTI, congenital anomalies
20-40 UTI, stones, bladder tumor
40-60 ♂: bladder tumor, calculi, UTI
♀: UTI, calculi, bladder tumor
>60 ♂: BPH, bladder tumor, UTI
♀: bladder tumor, UTI
HPI:
Characterize the hematuria:
- Is the blood visible or was it found on microscopy? (more likely to find cause of gross hematuria)
- At what point during urination is the blood seen? (initial – urethra; total – bladder or upper tract; terminal – bladder neck or prostatic urethra)
- Associated with pain? (can be due to cystitis, stone, or upper tract hematuria with obstruction of the ureters by clots)
- Are there any clots? (indicates more significant degree of hematuria)
- Do clots have a specific shape? (vermiform clots assoc’d with flank pain suggests upper tract origin)
- Systemic symptoms: fever, rash, joint pain (SLE), weight loss, night sweats
- Recent trauma, menstruation (endometriosis), sexual activity, infection (URTI, pharyngitis, skin infection, or rash + hematuria Þ poststreptococcal glomerulonephritis)
- Exercise
- Ingestion of drugs or foods that cause pseudohematuria
Meds: – NSAIDS, anticoagulants
PMHx: – calculi, flank pain, CA, infxns, renal disease, pelvic radiation
FHx: – renal disease (likely a glomerular leak), DM, sickle cell anemia, polycystic kidney disease, calculi
SHx: – smoking, occupational and environmental exposures (dyes, rubber compounds)
Physical Examination:
- General – cachexia
- Vitals – blood pressure, T, fluid status
- Abdomen – mass or tenderness
- GU – external genitalia; DRE in male >50
Investigations:
- CBC (anemia, leukocytosis), lytes, BUN, Cr
- Urine C&S, R&M; cytology
- Renal/ bladder US (renal US = initial test for upper tracts)
- CT (upper tracts)
- Cystoscopy +/- retrograde pyelogram (bladder/ ureters)
- Bladder tumor assays
If initial evaluation is negative & persistent hematuria, follow renal fnctn, UA, & cytology x 3 yrs
Re-evaluate if gross hematuria, irritative voiding sx, abnormal cytology