Approach to Gross Hematuria

Question 1

Definition of Gross Hematuria vs Microscopic?

Answer 1

Gross = Visibly bloody or brown urine
Microscopic = 3 or more RBC in properly collected urinalysis specimens

Question 2

What is a ‘properly collected’ urine specimen?

Answer 2

1. Freshly voided
2. Clean catch
3. Midstream

Question 3

What to ask on history?

Answer 3

1. Is the patient experiencing macroscopic or microscopic hematuria?
2. Mimickers
   - Beetroot
   - Levodopa, senna, rifampicin
   - porphyria, alkaptonuria, bilirubinuria
   - Menstruation
   - Exercise
   - Sexual Intercourse
   - Trauma
3. Etiology Suggestions
   - When does blood occur during urination - initial, terminal, throughout?
   – Initial;: disease in urethra, distal to the UG diaphragm
   – Terminal: disease near bladder neck or prostatic urethra
   – Throughout: disease in the bladder or upper urinary tract

• LUTS: FUN (Storage Problem eg UTI, stones, bladder tumour) DISH (Voiding problem eg BPH, Prostate Cancer, Urethral Stricture) + Polyuria, Oliguria, Urethral Discharge
• Upper Urinary Tract Symptoms: Loin Pain/Tenderness (eg renal infection, infarction, +/- obstruction and glomerulonephritis); pain with radiation to iliac fossa, groin and genitalia (acute obstruction of renal pelvis or ureter by calculus or clots)
• Painless vs painless hematuria (painless hematuria = malignancy; pain suggest infection/inflammation

4. Extra-glomerular or glomerular bleeding
   - Frothy urine: glomerular bleeding
   - Clots: extra-glomerular
   - Colour: Red-pink (extra-glomerular); Red-brown-coca-cola (glomerular)
   - RBC morphology: (Normal (extra-glomerular); RBCs dysmorphic (glomerular))
   - RBC Casts: Extraglomerular (absent); Glomerular (present)
5. Severity
   - Transient or persistent
   - Anemia
   - Concomitant renal impairment (urine amt, fluid overload status)
6. Red Flags
   - Male
   - Age > 35y
   - Past or current smoker
   - Occupational exposure - chemicals or dyes
   - Hx of exposure to carcinogenic agents or chemo
   - Hx of analgesic abuse
   - Hx of gross hematuria, uro disease, irritatice urinary symptoms, pelvic radiation, chronic UTI, chronic indwelling FB

Question 4

PE

Answer 4

1. Vitals
2. Anemia
3. Heart
4. Lungs
5. Abdomen
6. Extremities - edema, rashes (HSP, SLE, Vasculitis), joint pain
7. Scrotum - varicocele on left
8. DRE - enlarged prostate

Question 5

Ddx

Answer 5

Question 6

Investigations

Answer 6

Start with repeat urine dipsticks

Then renal imaging to exclude anatomical bleeding lesions

If absent, do full assessment

1. Urine Dipstick (initial, go on to UFEME)
2. UFEME - test for WBC, RBC, Epithelial cell, casts, crystals etc (absence of RBCs/casts despite +ve dipstick suggests hemoglobinuria or myoglobinuria)
3. Urine c/s (to exclude UTI)
4. Urine cytology (for suspected bladder cancer)
5. Urine Phase contrast (distinguish glomerular vs extraglomerualr)
6. Biochemical - FBC, RP
7. Plain KUB (must show pubic symphysis)
8. US Kidney
9. CT Urogram/ MR Urogram (3 phasesL non contrast (for stones), renal parenchymal (for tumours), delayed; for pt with unexplained persistent gross hematuria)
10. IV Urogram or IV Pyelogram: outline of renal and pelvic calyces (Control phase (before contrast), nephrogram phase (1min), pyelogram phase (3min), release film, post micturiation) (to delineate anatomical issues)
11. Cystoscopy (for pt with unexplained gross hematuria, passng of clots, persistent unexplained microscopic hematuria, detetction of bladder tumour, biopsy can be taken at same time) – gold standard for evaluating lower urinary tract
12. Renal Biopsy (for pt w glomerular hematuria with RF for prograssive disease