hematuria

Question 1

incidental asymptomatic microscopic hematuria - do not routinely screen, but if found needs thorough work-up

Answer 1

*determine risk for STD, chemical, strenuous exercise, drugs, meds, supplements
*urine culture to r/o infection
*repeat UA (need 2 positive tests before further workup, if high risk factors with low RBC # then still work up)
*if persists or high risk factors do work-up:
serum Cr
urine cytology r/o transitional cell carcinoma
image upper UT via IV pyelogram or CT scan, lower UT via cystoscopy, voided cytology to r/o malignancy (low incidence if asymptomatic)

Question 2

urinary tract cancers

Answer 2

renal cell carcinoma

transitional cell carcinoma (bladder + urethra)

Question 3

visible blood in urine (red, brown)

Answer 3

gross hematuria

Question 4

lower urinary tract

Answer 4

bladder + urethra

Question 5

upper urinary tract

Answer 5

kidney + ureters

Question 6

3 or more RBCs/HPF on 2 or more UAs (incidental finding usually)

Answer 6

microscopic hematuria

Question 7

causes of hematuria

Answer 7

glomerular: + lots protein, RBC casts, dysmorphic RBCs
renal: secondary to tubulointerstitial, renovascular (hypertension, diabetes, autoimmune), metabolic d/o, + lots protein only, RBC casts
urologic: tumor, kidney stones, infection, trauma, BPH, NO protein, casts, etc.

Question 8

properly collected UA

Answer 8

freshly voided
early morning
clean-catch (reduce FP rate)
midstream 
examine within 2 hours and refrigerate

Question 9

ways of measuring hematuria

Answer 9

number of RBCs/mL of urine excreted (chamber count)
direct examination of centrifuged urinary sediment (sediment count)
indirect exam of urine by dipstick (simplest way low specificity (can’t distinguish RBC from myoglobin or hemoglobin) - must be confirmed by microscopic evaluation of urinary sediment)
-look for dysmorphic RBCs, casts, eosinophils

Question 10

risk factors for malignancy

Answer 10

smoking
chemical or dye exposure (benzene, aromatic amines)
hx of gross hematuria
>40 yo
hx of urologic d/o or disease
hx of irritative voiding dx
hx of UTI
analgesic abuse (causes interstitial nephritis)
hx of pelvic radiation

Question 11

urinary sediment can distinguish

Answer 11

glomerular disease from interstitial nephritis:
RBC casts + dysmorphic RBC = renal glomerular disease
eosinophils = interstitial nephritis (analgesics)

Question 12

causes of transient microscopic hematuria (negative 2nd UA)

Answer 12

sexual intercourse
heavy exercise (resolves in 3 days)
recent digital prostate examination
menses contamination

Question 13

if microscopic hematuria and + UA for infection

Answer 13

obtain urine culture (clean catch, midstream)
treat UTI
repeat UA in 6 weeks

Question 14

upper urinary tract imaging

Answer 14

IVP w/ contrast or US (no contrast): may miss small lesions
CT scan: high sensitivity/specificity for masses, stones, infections, obstruction (no contrast for stones then do contrast)
N-acetylcysteine or IV NaHCO3 to reduce risk of contrast nephropathy

Question 15

if workup for microscopic hematuria is negative

Answer 15

f/u bp, UA, voided urine cytology at 6, 12, 24, 36 mo
if negative and asymptomatic no further work-up
if becomes gross hematuria, voiding difficulties, pain, abnormal cytology - consult urology
if get HTN, proteinuria, glomerular casts, abnormal renal function - consult nephrology

Question 16

gross hematuria - always need full work-up

Answer 16

UA + urine culture

image upper UT via CT scan

Question 17

dysuria + UA with microscopic hematuria

boggy, tender prostate

Answer 17

prostatitis
1 mo antibiotics
f/u UA and culture, if still + need further work-up