Hematuria/Dark Urine

Question 1

Differential diagnoses of Hematuria

Answer 1

1. Renal Cell Carcinoma*
2. Benign Prostatic Hyperplasia*- Bladder outlet obstruction

Probability diagnosis Infection:
•cystitis (both sexes)/urethrotrigonitis (female)
•urethritis (male)
•prostatitis (male)
Calculi-kidney, ureteric, bladder
Bladder tumour

Serious disorders not to be missed  
Cardiovascular:
•kidney infarction
•kidney vein thrombosis
•prostatic varices

Neoplasia/cancer:
•kidney tumour
•urothelial: bladder, kidney, pelvis, ureter
•prostate cancer

Infection:
•infective endocarditis
•kidney tuberculosis
•acute glomerulonephritis
•blackwater fever (falciparum malaria)
IgA nephropathy 
Kidney papillary necrosis
Other kidney disease

Pitfalls (often missed) 
Urethral prolapse/caruncle 
Pseudohaematuria (e.g. beetroot, porphyria)
Benign prostatic hyperplasia 
Trauma: blunt or penetrating 
Foreign bodies
Bleeding disorders
Haemorrhagic cystitis
Exercise (esp. long distance running)
Radiation cystitis
Menstrual contamination

Rarities:
•hydronephrosis
•Henoch–Schönlein purpura
•schistosomiasis (bilharzia)
•polycystic kidneys
•kidney cysts
•endometriosis (bladder)
•systemic vasculitides

Masquerades checklist
Drugs (cytotoxics, anticoagulants)
UTI

Is the patient trying to tell me something?
Consider artefactual haematuria.

Question 2

Hematuria - Key History

Answer 2

Key history

Is it really haematuria?
Red discolouration can be due to haemolysis or red food dye.

The history should include nature of haematuria, associations such as pain, sexually transmitted infections, dysuria and frequency.

Drug history, athletic history, urological history, sexual history, recent trauma history, travel history.

Question 3

Hematuria - Key PE

Answer 3

Key examination

• General examination and vital signs, especially BP
• Cardiovascular examination to exclude possible kidney embolisation
• Abdomen examination especially for a palpable enlarged kidney or spleen
• Suprapubic examination for bladder tenderness or enlargement
• Consider rectal examination in men and vaginal examination in women

Question 4

Hematuria - Key Investigation

Answer 4

Key investigations

• Urine analysis
• Urine MC
• Urine cytology
• FBE/ESR
• Appropriate radiology (e.g. intravenous urogram, intravenous pyelogram, ultrasound.
• Direct imaging (e.g. cystoscopy)

Question 5

Hematuria - Diagnostic tips

Answer 5

Diagnostic tips

• Macroscopic haematuria is always abnormal except in menstruating women.
• Common sources of macroscopic haematuria are the bladder, urethra, prostate and kidney.
• Joggers and athletes engaged in very vigorous exercise can develop transient microscopic haematuria.
• Common urological cancers that cause haematuria are the bladder (70%), kidney (17%), kidney pelvis or ureter (7%) and prostate (5%).
• The key radiological investigation is the intravenous urogram (pyelogram).
• Sometimes blood in the urine can come from the rectum or vagina.
• Painless frank haematuria is an ominous sign