Hematuria

Question 1

Microscopic hematuria

Answer 1

presence of 3 or more RBCs per HPF on two or more properly collected UA

Question 2

Etiologies of hematuria (name three classes)

Answer 2

glomerular, renal (nonglomerular), and urologic

Question 3

glomerular hematuria characteristics

Answer 3

• associated with dysmorphic RBCs, erythrocyte casts, and significant proteinuria

Question 4

renal hematuria characteristics

Answer 4

• significant proteinuria but no dysmorphic RBCs or erythrocyte casts
• secondary to tubulointerstitial, renovascular, and metabolic disorders

Question 5

urologic hematuria characteristics

Answer 5

• caused by tumors, calculi, infections, trauma, BPH

- NO proteinuria, dysmorphic RBCs, or erythrocyte casts

Question 6

When to start routinely screening for bladder cancer

Answer 6

NOT RECOMMENDED IN ASYMPTOMATIC PATIENTS, even though malignancy is found in 5% of all patients with incidental asymptomatic microscopic hematuria

Question 7

Ways to quantitatively measure hematuria

Answer 7

chamber count, sediment count, dipstick (simplest way, but limited specificity)

Question 8

What to do if urine dipstick positive for hematuria

Answer 8

evaluate urinary sediment

Question 9

risk factors for bladder cancer

Answer 9

• smoking
• age older than 40
• history of gross hematuria
• occupational exposure to chemicals or dyes (benzenes or aromatic amines)
• hx of UTI
• analgesic abuse

Question 10

What to do if UA shows significant proteinuria, red cell casts, renal insufficiency, or predominance of dysmorphic RBCs

Answer 10

evaluate for renal parenchymal disease or refer to nephrologist

Question 11

How to distinguish glomerular bleeding from lower urinary tract bleeding

Answer 11

glomerular - associated with mostly dysmorphic RBCs

lower urinary tract - associated with mostly normal RBCs

Question 12

How to distinguish glomerular disease and interstitial nephritis

Answer 12

evaluate urinary sediment!

glomerular - dysmorphic RBCs, erythrocyte casts,
interstitial nephritis - eosinophils, often caused by analgesics or other drugs

Question 13

If UA with microscopy positive for hematuria and probable cause is determined (menstruation, drugs, strenuous exercise, recent urologic procedure), what to do next?

Answer 13

repeat UA with microscopy 6 weeks after cause is discontinued/treated, if negative again and asymptomatic, no further work up needed

Question 14

what can cause transient microscopic hematuria

Answer 14

intercourse, strenuous physical exercise (resolves in 72 hours), digitial prostate exam, menses contamination

Question 15

How to rule out UTI

Answer 15

urine culture

Question 16

Full workup of microscopic hematuria

Answer 16

• detailed physical and history
• UA with microscopy (repeat if needed)
• assessment of renal function (creatinine, GFR to rule out renal parenchymal disease)
• urine culture to rule out UTI
• imaging of upper and lower urinary tract (i.e. CT urography)

always try to rule out malignancy! (renal cell carcinoma or transitional cell carcinoma)

Question 17

If thorough work up for hematuria is negative, how often to follow up?

Answer 17

UA with microscopy repeated annually for 2 consecutive years

Question 18

If persistent asymptomatic microscopic hematuria…

Answer 18

repeat evaluation within 3-5 years of initial eval