Gross Hematuria

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)
• 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