Hematuria

Demographics: Etiology varies with patient age, type of hematuria (gross or microscopic, symptomatic or asymptomatic), and existence of risk factors for urologic malignancy (see below)

o   ~ 5% of patients with microscopic hematuria and up to 40% of patients with gross hematuria have cancer of the genitourinary tract. It is best to assume any degree of unexplained hematuria is of malignant origin, until proven otherwise

o   in ~ 40% of patients with asymptomatic microhematuria, no identifiable source is found

 

 

History: medical and surgical history, family history, social history, occupational or radiation exposure, and medications taken.

a.       frequency and dysuria may suggest urinary tract infection, whereas colicky pain suggests urolithiasis

b.      Presence of prostatism-related lower urinary tract symptoms

c.       Recent upper respiratory tract or skin infection may be associated with glomerulonephritis

d.      Recent menstruation, vigorous exercise, or sexual activities may produce transient hematuria in otherwise healthy patients.

e.      A family history of polycystic kidney disease and other renal diseases, sickle cell anemia, and

f.        history of travel to areas with endemic schistosomiasis, malaria, or tuberculosis

 

 

Physical Exam:  hypertension (nephritic syndrome), edema (nephrotic syndrome), palpable abdominal or flank mass (renal neoplasm), CVA or suprapubic tenderness (UTI), rectal exam in men (may reveal prostatic nodularity)

 

 

 

Differential Diagnosis:

Mnemonic: "HITTERS"

• Hematologic disorders  - i.e. thrombocytopenia, coagulopathy
• Infection (cystitis), Inflammation (e.g. from drugs like Cyclophosphamide)
• Tumor – most common = bladder ca, renal cell ca
• Trauma
• Exercise -heavy and strenous
• Renal disorder – e.g. Glomerulonephritis
• Stones

Clearly, there are some more urgent things on this list that need to be evaluated.  In general, hematuria in an elderly adult is malignancy (either bladder or renal) until proven otherwise.

 

 

 

Laboratory Studies: UA with microscopy, CBC, chem 7,  and urine culture. pts with documented UTI or calculi should have a UA repeated in 2-6 weeks (after resolution of sxs) to ensure resolution of hematuria. The presence of dysmorphic RBCs, RBC casts, or proteinuria supports a glomerular origin

o   Dipsticks  are very sensitive for hematuria (1 to 2 RBCs/HPF can be detected) , but not specific (false + can be seen with hemoglobinuria, myoglobinuria, and urine contaminants)-- a positive test result (whether trace or 3+) should immediately be followed by a microscopic examination of the urinary sediment to confirm or exclude the presence of RBCs

o   gross discoloration of urine should not be presumed to be due to hematuria because a range of dietary, metabolic, and pharmacologic factors such as beets, blackberries, melanin, bile, porphyrin, iron, and various medications can also be responsible

 

 

 

Imaging/other: Urologic eval of upper and lower urinary tracts is necessary in all pts with gross hematuria, and should be considered in high-risk individuals with microhematuria  

- Cytologic evaluation of the urine demonstrates excellent sensitivity and specificity for high-grade urothelial carcinoma, but has limited (45%–70%) sensitivity and specificity for low-grade disease

 

 

 

Risk factors for urothelial cancer in patients with microscopic hematuria

·         Smoking history

·         Occupational exposure to chemicals or dyes (benzenes or aromatic amines)

·         History of gross hematuria

·         Age greater than 40 years

·         History of urologic disorder or disease

·         History of irritative voiding symptoms

·         History of urinary tract infection

·         Analgesic abuse

·         History of pelvic irradiation

 

 

Neobladders:

· Orthotopic neobladders are internal reservoirs that are connected to the native urethra and rely upon the external striated sphincter for continence

· Reservoir is constructed from a segment of detubularized intestine (usually ileum) anastomosed to the native urinary outflow tract—the distal ileum and/or cecum are used most often because these sites have the fewest metabolic consequences

· Electrolyte and metabolic abnormalities differ based upon the bowel segment used for the diversion (result from resorption of excreted metabolites through the intestinal mucosa)

· While most metabolic abnormalities are clinically subtle, they may assume significance in patients with renal insufficiency: metabolic acidosis (↑ Cl, ↓ bicarbonate, azotemia)

·  Some compromise of renal function over time may be observed in some patients after urinary diversion (multifactorial due to development of urinary tract obstruction (at the site of either ureteral implantation site or reservoir/conduit outflow), stones, and chronic infection

 

 

 

 

(Victoria Kelly MD, 1/31/11)

(Chanu Rhee MD, 10/22/10)