Hematuria

From Anvita Health Wiki

Contents 1 Introduction 2 Etiology 3 History 4 Clinical-manifestations 5 Laboratory 6 Diagnostic-procedures 7 Radiology 8 Complications 9 Management 10 More General Terms 11 Additional Terms 12 References

Introduction

• Blood in the urine. Generally > 3-5 RBC/ hpf is considered abnormal.

Etiology

• infection

• cystitis
• pyelonephritis
• urethritis
• prostatitis

• benign prostatic hypertrophy ( BPH)
• nephrolithiasis
• urogenital neoplasms

• bladder
• renal
• prostate
• ureteral

• renal disease

• glomerulonephritis
• benign familial hematuria
• hypertensive nephrosclerosis
• IgA nephropathy
• runner's hematuria
• drug-induced hematuria
• papillary necrosis
• polycystic kidney disease
• renal infarct
• medullary sponge disease
• obstructive or reflux nephropathy
• tuberculosis
• renal vein thrombosis

• coagulopathy
• sickle cell disease
• trauma

• indwelling catheter
• meatal ulceration

• endometriosis
• pharmacologic agents

• cyclophosphamide
• penicillamine
• gold salts

• false-positives may be due to:

• beets
• blackberries
• vaginal bleeding
• myoglobin
• drugs

• rifampin
• phenytoin
• ibuprofen

• idiopathic: often no etiology is found

History

• dysuria, frequency, pain, fever, bleeding between voidings, menstruation, renal stones & passage of stones, joint pain, color, timing, pattern: initial hematuria (anterior urethral lesion), terminal hematuria ( bladder neck or prostate lesion) hematuria throughout voiding (bladder or upper urinary tract), recent sore throat, streptococcal skin infection or upper respiratory tract infection, prior kidney infections, joint pain, travel, exposure to toxins

Clinical-manifestations

• otherwise asymptomatic hematuria is common
• terminal hematuria (i.e. noted in later phase or with termination of urination) may arise from the bladder neck, posterior urethra or prostate (men)
• blood arising independently of urine arises from the terminal urethra
• brown or smokey urine arises from the kidney
• gross hematuria is far more likely than microscopic hematuria to have a serious cause
• manifestations of specific etiology

Laboratory

• general investigation

• urinalysis with microcospic examination

• RBC casts & proteinuria suggest glomerulonephritis
• pyuria suggests UTI
• repeat microscopic hematuria
• dipstick

• detects > 5 RBC/ hpf
• detects hemoglobin & myoglobin
• false positives

• ascorbate > 5 mg/dL
• contamination with povidone-iodine

• hypercalciuria

• found is 1/3 of children referred for hematuria
• found in some adults
• 15% will develop nephrolithiasis

• proteinuria & dysmorphic erythrocytes or RBC casts accompanying microscopic hematuria suggests glomerular etiology
• hematuria without proteinura, dysmorphic erythrocytes or RBC casts suggests extraglomerular bleeding (i.e. nephrolithiasis, cancer, trauma, infections, medications)
• serum chemistries

• serum urea nitrogen
• serum creatinine

• urine cytology for patients age > 50 years

• false positives may occur with nephrolithiasis

• investigation guided by history, physical exam, urinalysis

• urine culture if indicated by urinalysis
• complete blood count ( CBC)
• PT/PTT
• prostate-specific antigen (PSA)
• electrolytes
• serologies

• antinuclear antibodies ( ANA)
• antistreptolysin O ( ASO)
• rapid plasma reagin (RPR)

• urine protein electrophoresis
• hemoglobin electrophoresis
• tuberculin skin test
• urine for acid-fast bacilli
• immunohistochemical staining of erythrocytes for Tamm- Horsfall protein suggests renal origin

Diagnostic-procedures

• cystoscopy

Radiology

• abdominal ultrasound (confirmed microscopic hematuria)
• plain film ( X-ray) of abdomen ( KUB)
• intravenous pyelogram ( IVP) for gross hematuria in the absence of infection
• computed tomography ( CT) if ultrasound shows solid or complex renal mass, or gross hematuria

Complications

• 0.7% of patients with persistent microscopic hematuria will develop end-stage renal disease [5]

Management

• etiology-specific
• idiopathic hematuria

• patient education

• incidence of future serious disease is low

• follow up:

• age > 50 years

• urine cytology every 6 months
• yearly cystoscopy

• age < 50 years: observation

• confirmed microscopic hematuria

• ultrasound of kidneys
• plain abdominal films ( KUB)
• refer to urology for cystoscopy
• asymptomatic microcopic hematuria in children with otherwise normal exams may not require diagnostic evaluation [4]

• gross hematuria (not cystitis or pyelonephritis)

• intravenous pyelogram
• computed tomography ( CT)
• refer to urology for cystoscopy
• carcinoma of the bladder is the most serious cause

• high risk: treat as gross hematuria

• smoking
• exposure to benzene or aromatic amines
• age > 40 years
• history of urologic disorder
• dysuria
• analgesic abuse
• pelvic irradiation

More General Terms

• sign/symptom

Additional Terms

• causes of hematuria
• hemoglobinuria
• pharmaceutical agents associated with hematuria

References

1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 829-39
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 518-519
3. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, American College of Physicians, Philadelphia 1998, 2009
4. Journal Watch 25(11):90-91, 2005 Bergstein J, Leiser J, Andreoli S. The clinical significance of asymptomatic gross and microscopic hematuria in children. Arch Pediatr Adolesc Med. 2005 Apr;159(4):353-5. PMID: [1]
   - Stapleton FB. Asymptomatic microscopic hematuria: time to look the other way? Arch Pediatr Adolesc Med. 2005 Apr;159(4):398-9. No abstract available. PMID: [2]
5. Vivante A et al. Persistent asymptomatic isolated microscopic hematuria in Israeli adolescents and young adults and risk for end-stage renal disease. JAMA 2011 Aug 17; 306:729 PMID: [3]
6. Hematuria (Blood in the Urine) [4]
7. National Guideline Clearinghouse
   - Hematuria. (Intracorp) ngc-guideline: [5]
   - Haematuria. (Finnish Medical Society Duodecim) ngc-guideline: [6]
   - ACR Appropriateness Criteria: hematuria (American College of Radiology) ngc-guideline: [7]
   - Hematuria-child. (American College of Radiology) ngc-guideline: [8]

hematuria