Approach to Hematuria

Question 1

Hematuria: Gross vs. Microscopic

Answer 1

Gross Hematuria: Blood in the urine that is visible to the naked eye
Microscopic Hematuria: Blood in the urine that is detectable only on examination of the urine sediment by microscopy

Question 2

Hematuria Etiology:

Answer 2

• Renal: Malignant mass (10%), benign mass,
  glomerular, structural – polycystic or
  medullary sponge (20%), pyelonephritis,
  hydronephrosis
• Ureter & Renal Pelvis: Stones (40%), malignancy (5%), stricture
• Bladder: Malignancy, cystitis (UTI, radiation,
  interstitial cystitis, medications)
• Prostate/Urethra: Benign prostatic hyperplasia (BPH), prostate cancer, urethritis,
  catheterization, procedures

Question 3

False Positive causes for hematuria

Answer 3

Gross hematuria
● Menstruation
● Pyridium, rifampin, nitrofurantoin
● Beeturia
● Factitious

Urine Dip Hematuria
● Myoglobinuria or hemoglobinuria

Question 4

Risk Factors for Hematuria

Answer 4

● Age >35 years old
● Male
● Hx of smoking
● Occupational exposures
● Hx of analgesic abuse
● Hx of gross hematuria
● Hx of chronic UTI
● Hx irritative voiding Sx
● Hx of chronic indwelling
foreign body
● Family Hx (sickle cell, lynch syndrome)

Question 5

Chronic bladder irritation is caused by:

Answer 5

● Hx of gross hematuria
● Hx of chronic UTI
● Hx irritative voiding Sx
● Hx of chronic indwelling
foreign body

Question 6

Hematuria presentation

Answer 6

• Gross hematuria –Red or brown urine (1 mL blood/1L urine)
  ● Flank pain with radiation → stone
  ● Fevers, dysuria, WBCs → possible UTI
  ● LUTs → BPH
  ● New onset HTN or edema → nephritic syndrome
  ● Recent URI → postinfectious GN or IgA nephropathy
  ● Family history of hematuria → genetic (i.e. PCKD, IgA or sickle cell
  nephropathy)

Question 7

Hematuria at the Beginning of urine stream suggests ______

Answer 7

urethral bleeding

Question 8

Hematuria at the end of the urine stream suggests _____

Answer 8

bladder or prostatic bleeding

Question 9

Hematuria History clues

Answer 9

• Recent vigorous exercise or trauma
• Hx of a bleeding disorder
• Contamination with menstrual blood
• Medication use: Nephrotoxic drugs
  ● Travel or residence in areas endemic for Schistosoma or TB
  ● Sterile pyuria with hematuria → renal TB, toxic nephropathy, etc.
• Asymptomatic – found incidentally on urine dip

Question 10

Transient Hematuria

Answer 10

The temporary presence of blood in the urine
○ Typically resolves within 48-72 hours
○ Common in adolescents and young adults – typically benign with no identifiable cause

Question 11

Causes of Transient Microscopic Hematuria

Answer 11

• UTI, vigorous physical exercise*, sexual intercourse, trauma,
  prostate examination, or menstrual contamination
• In the absence of signs or Sx, have the patient avoid possible transient
  causes and repeat the urinalysis in a few days (4-6 wks exercise induced)

Question 12

Approach to the red/brown urine sample

Answer 12

Centrifuge urine
○ Red Sediment = hematuria (proceed to
hematuria algorithm)
■ Casts, dysmorphic RBCs, proteinuria→
glomerular → Nephrology
■ Clots → non-glomerular → Urology
(Urgent CT & Cysto)
○ Red Supernatant
■ Myoglobinuria, hemoglobinuria
● Dipstick heme to R/O false positives

Question 13

Diagnosis of Hematuria reqs

Answer 13

○ Centrifuge urine
■ Red/brown sediment → Dx of hematuria is confirmed
■ > 3 RBC/hpf (from sediment after centrifuge)

Question 14

Approach to hematuria once diagnosed

Answer 14

• > 3 RBC/hpf
• History and physical – emphasis on possible urothelial cancers and non-cancerous cause
• Treat or identify easily identifiable causes (don’t need full work-up)

Question 15

Approach to low risk microscopic hematuria and how will you treat?

Answer 15

○ Women < 50; Men < 40
○ Never smoker or < 10 pack-year
○ 3-10 RBC/hpf on one UA
○ No other malignant risk factors
○ No past episodes of microscopic hematuria
* Evaluation
○ Repeat UA in 6 months (depending on risk)
OR
○ Cystoscopy and renal U/S

Question 16

Approach to moderate risk microscopic hematuria and how will you treat?

Answer 16

○ Women 50-59; Men 40-59
○ 10-30 pack-year smoking
○ 11-25 RBC/hpf on one UA
○ > 1 malignant risk factor
○ Previous low-risk with no prior eval, but 3-25 RBC/hpf on repeat UA
* Evaluation: Cystoscopy and renal ultrasound

Question 17

Approach to high risk microscopic hematuria and how will you treat?

Answer 17

○ Women & Men > 60
○ > 30 pack-year smoking
○ > 25 RBC/hpf on one UA
○ Hx of gross hematuria
○ Previous low-risk with no prior eval, but > 25 RBC/hpf on repeat UA
* Evaluation: Cystoscopy and CT Urogram

Question 18

Approach to negative workup for microscopic hematuria and how will you treat?

Answer 18

○ Repeat UA within 12 month
* If at any point in time a patient has an episode of gross hematuria or an increase in the amount of RBC/hpf, restratify risk and
restart work-up

Question 19

Approach to glomerular hematuria and how will you treat?

Answer 19

• Glomerular hematuria – typically painless
• Edema, elevated serum creatinine, proteinuria, casts, dysmorphic RBCs
• May need renal biopsy to diagnose