Hematuria
Adult-Gerontology Acute Care Practice Guidelines
Definition
A.Gross hematuria: Visible blood in the urine.
1.Visible blood in the urine may be seen with as little as 1 mL of blood in 1 L of urine.
B.Microscopic hematuria: Greater than three red blood cells (RBCs) per high power field in a single urinalysis.
Incidence
A.Population-based studies have shown prevalence rates of less than 1% to as high as 16%.
B.Older men have a higher prevalence of hematuria.
C.Associated conditions.
1.No diagnosis after workup: 60.5%.
2.Urinary tract infection (UTI): 13%.
3.Stone disease: 3.6%.
4.Cancer: 13%.
5.Glomerular disease: 9.8%.
Pathogenesis
A.Glomerular or nephronal hematuria (originates from nephron).
1.On microscopic evaluation, RBCs that are dysmorphic (irregular shapes and uneven hemoglobin distribution) often represent glomerular disease. There may be casts.
2.On urinalysis, the combination of RBCs and proteinuria most often indicates a glomerular source of hematuria.
B.Extraglomerular hematuria (originates from urologic source): Anything that disrupts the genitourinary (GU) epithelium, which may include irritation, trauma, inflammation, or invasion.
1.On microscopic evaluation, the RBCs in the urine are isomorphic; have smooth, round membranes; and display even hemoglobin distribution.
2.Associated conditions include tumors, kidney stones, trauma, infection, anatomic abnormalities of the urinary tract such as ureteropelvic junction obstruction, and benign prostatic hypertrophy (BPH).
Predisposing Factors
A.Age greater than 35.
B.Smoking history.
C.Recent trauma.
D.Recent urinary tract surgery or instrumentation.
E.BPH.
F.Family history of renal disease.
G.Personal history of nephrolithiasis.
H.Pelvic radiation.
I.Recent febrile illness.
J.Frequent UTIs.
K.Occupational exposure to chemicals and dyes (benzenes or aromatic amines).
L.Medications (abuse of analgesics such as nonsteroidal anti-inflammatory drugs [NSAIDs]).
M.Chronic indwelling catheters (Foley, suprapubic tube).
Subjective Data
A.Common complaints/symptoms.
1.Flank pain: Possible recent trauma, stones, renal cancer, ureteral tumor, or pyelonephritis.
2.Dysuria/lower urinary tract symptoms (LUTS) such as urgency/frequency and urinary retention: Possible UTI/prostatitis, BPH, or bladder stones.
3.Fever: Possible UTI, prostatitis, or pyelonephritis.
4.Worm-like (vermiform) clots: Possible origin from upper urinary tract.
B.Common/typical scenario.
1.Visual appearance of blood in the urine or presence with microscopic hematuria.
2.Timing of hematuria during urinary stream: May indicate the site of pathology (i.e., initiation of stream—anterior urethral pathology; termination of stream—bladder neck, prostate, or urethra inflammation/pathology; throughout stream—bladder or upper urinary tract origin).
3.Aggravating factors.
a.Pain, recent trauma, or recent vigorous activity/exercise.
b.Recent upper respiratory infection (associated with glomerulonephritis).
c.Ingestion of certain foods and drugs (pseudohematuria).
d.Excessive use of analgesics such as NSAIDs.
C.Family and social history.
1.Smoking (past or present).
2.Excessive ingestion of barbecued/smoked foods (associated with link to bladder cancer).
3.Sexual history (recent sexually transmitted infections [STIs]).
4.Work history: Exposure to chemicals and dyes in rubber and/or petroleum industries (associated with bladder cancer).
5.Family history.
a.GU malignancies.
b.Primary renal disease.
c.Polycystic kidney disease.
d.Nephrolithiasis.
e.Hypertension.
D.Review of systems.
1.Constitutional symptoms: Recent weight loss, fevers, or night sweats that may indicate malignancy.
2.Respiratory: Cough or shortness of breath that may indicate recent upper respiratory infection or tumor invasion.
3.Musculoskeletal: Generalized pain may indicate excessive NSAID use.
4.GU: LUTS, flank pain, dysuria, cloudy urine, or foul smelling urine.
5.Gynecologic: Menorrhagia.
6.Gastrointestinal: Nausea, vomiting, or abdominal pain may indicate renal mass, or nephrolithiasis.
7.Neurological: Confusion, dizziness, or mental status changes may indicate metastatic malignant disease (renal cancer).
8.Skin: Rashes or pallor that may be associated with systemic lupus erythematosus.
9.Hematologic: Excessive bruising or petechiae may indicate blood clotting disorder.
10.Ear, nose, and throat (ENT): Frequent nosebleeds, rhinorrhea, or sinus congestion.
Physical Examination
A.Vital signs.
1.Temperature: Measurement greater than 101.5°F may indicate UTI, pyelonephritis, or prostatitis.
2.Blood pressure.
a.Hypertension: Glomerular source or renal failure.
b.Hypotension: Possible acute blood loss anemia from gross hematuria.
3.Pulse: Tachycardia, sepsis, or hypovolemia from acute blood loss anemia.
B.Skin: Rashes, pallor, or bruising/lacerations from recent trauma.
C.Edema: Possible nephrotic syndrome; rule out deep vein thrombosis (DVT) from GU malignancy.
D.GU examination.
1.Costovertebral angle tenderness: Nephrolithiasis; pyelonephritis.
2.Urethral trauma: Urethral caruncle, vaginal prolapse, phimosis, obvious urethral stricture.
E.Digital rectal exam (DRE).
1.Boggy, tender warm prostate: Acute prostatitis.
2.Nodularity: Prostate cancer.
Diagnostic Tests
A.Urinalysis.
1.Color: Red (recent bleeding, most likely urologic source) versus brown or tea color (old blood clots or renal disease).
2.Proteinuria: Heavy 3 to 4+ (renal disease).
3.Leukocyte positive and/or nitrite positive: Infection.
4.Pyuria: Infection.
5.Red cell casts: Glomerular bleeding.
6.Crystalluria: Possible nephrolithiasis.
B.Phase contrast microscopy: Helps differentiate renal (presence of distorted RBCs) versus nonglomerular bleeding.
C.Urine culture: Evaluate for infectious sources.
D.Laboratory/blood work.
1.Complete blood count (CBC): Anemia.
2.Basic metabolic panel: Renal function.
3.Prothrombin time (PT)/partial thromboplastin time (PTT) and international normalized ratio (INR): Bleeding disorders.
E.Urine cytology.
1.Recommended for all patients with risk factors for GU malignancy and with LUTS and voiding symptoms.
2.Not recommended by the American Urologic Association as part of the routine evaluation of asymptomatic microhematuria.
3.Negative result does not rule out malignancy.
4.False positive results can be seen with calculi or inflammation.
F.Imaging.
1.Computed tomographic urogram (CTU) with and without contrast: Gold standard.
a.Three phase test.
b.Used to assess for stones (non contrast image); tumors of bladder or kidneys; hydronephrosis; other anatomic abnormalities (contrast image); tumors of upper tract; and collecting system filling defects (excretory phase).
c.Contraindicated with a serum creatinine greater than 2 mg/dL.
d.Highest sensitivity and specificity.
2.MRI/magnetic resonance urography (MRU; MRI urogram): Alternative imaging modality when not able to perform CTU due to renal insufficiency, contrast allergy, or pregnancy.
a.Less sensitivity at recognizing calculus of the GU tract.
3.Renal ultrasound: Not as specific or sensitive.
a.Can be used to grossly rule out clots in bladder or to detect hydronephrosis.
G.Diagnostic procedures/surgery.
1.Cystoscopy.
a.Indicated for all patients older than 35 years of age with microscopic hematuria or gross hematuria.
b.Also indicated for patients younger than 35 years of age with risk factors for GU malignancies and smoking history.
2.Retrograde pyelogram with or without ureteroscopy: May be performed to evaluate the upper tract in patients who are unable to have intravenous contrast for the CTU/MRU imaging.
3.Renal biopsy: Nephrology referral if glomerulonephritis is suspected.
Differential Diagnosis
A.Pseudohematuria: Certain foods, beets/certain drugs, or phenazopyridine (Pyridium).
B.Hereditary disorders: Polycystic kidney disease, nephropathy, renal tubular acidosis, or cystinuria.
C.Hematologic abnormalities: Bleeding disorders or sickle cell disease.
D.Anatomic abnormalities: Urethral strictures, ureteral strictures, ureteropelvic junction obstruction, urethral caruncle, or phimosis.
E.Vascular malformations (hemangioma).
F.Trauma: Abdominal and pelvic injury (degree of hematuria is a poor indicator of the severity of the injury).
G.Exercise-induced hematuria.
H.Foreign bodies (catheters, ureteral stents, self-introduced foreign body into urethra).
I.Infectious (UTI, pyelonephritis, prostatitis, schistosomiasis, tuberculosis).
J.Radiation (radiation cystitis and nephritis).
K.Stones of the GU tract.
L.Malignancy (renal, bladder, ureteral, prostate, penile, urethral, vulvar).
M.Benign tumor.
N.BPH.
O.Endometriosis of urinary tract (cyclic hematuria).
P.Benign essential hematuria.
Q.Glomerulonephritis or renal disorders (IgA nephropathy, drug-induced nephropathy).
R.Overanticoagulation with medications such as warfarin.
1.Clinical caveat—patients should still be thoroughly evaluated for other possible causes.
Evaluation and Management Plan
A.General plan.
1.Urinalysis, urine culture, and laboratory tests (see section “Diagnostic Tests“).
2.Urine cytology if indicated.
3.Imaging (CTU).
4.Patients with gross hematuria and/or urinary retention.
a.Place three-way Foley catheter (22–24 French most commonly used) and irrigate clots (continuous bladder irrigation with sterile saline solution).
b.If bleeding is not controlled, propose evaluation with urologic surgery for cystoscopy under anesthesia for clot evacuation/fulguration.
5.Patients who are voiding without clots or urine retention: Observation, with increase in oral fluid intake.
6.Patients with gross hematuria or history of trauma for acute blood loss anemia: Monitor with serial hemoglobin and hematocrit and transfuse as indicated.
B.Patient/family teaching points.
1.Provide patient education and prognosis depending on the cause of the hematuria.
2.Explain the various tests that are necessary to determine the cause of bleeding and the treatments that may be necessary for control of gross hematuria (e.g., cystoscopy, clot evacuation, Foley catheter placement for bladder irrigation).
3.Help to ease anxiety by providing appropriate analgesics (e.g., lidocaine jelly before placing a three-way catheter or narcotics/anticholinergics for painful bladder spasms due to clot retention/catheter placement).
C.Pharmacotherapy.
1.No specific medications are primarily indicated to treat hematuria.
2.Appropriate antimicrobials may be used to treat underlying infections.
3.Finasteride may be helpful in controlling bleeding from the prostate.
D.Discharge instructions.
1.Advise patients to refrain from vigorous activity for one week after gross hematuria has resolved.
2.Avoid NSAIDs and aspirin (if possible, some patients may need to continue based on history of coronary artery disease) for 3 days.
3.Advise patients that it is normal to have tea-colored urine for a few days as the hematuria is resolving.
4.Recommend that patients drink plenty of fluids.
5.Suggest that patients prevent constipation and straining by taking stool softeners such as docusate sodium.
6.Advise that patients should seek medical attention promptly if they develop bright red urine, pass clots, are unable to urinate, or have fevers or chills.
Follow-Up
A.Follow-up as indicated for the condition that is causing the hematuria.
B.Once the condition has resolved, reevaluate for microhematuria.
C.In asymptomatic microhematuria with a negative work-up, follow-up annually for repeat urinalysis/microscopy. If negative for 2 years, release from care. If positive, repeat imaging every 3 years and refer for renal evaluation.
Consultation/Referral
A.Nephrology consult for nephrogenic source of hematuria.
B.Urology consult for stones, tumors of the GU tract, BPH, anatomic evaluation, and control of bleeding.
C.Infectious disease consult for treatment of infectious sources (pyelonephritis, prostatitis, UTIs, possible tuberculosis work-up, or possible schistosomiasis).
D.Rheumatology consult for autoimmune disorders such as systemic lupus erythematosus.
E.Hematology consult for bleeding disorders.
Special/Geriatric Considerations
A.Screen elderly individuals appropriately for renal function prior to obtaining imaging studies with contrast.
B.The reduced capacity to retain salt and water increases as the kidney ages, predisposing to dehydration.
C.Older individuals are more susceptible to acute kidney injury from acute blood loss anemia and certain medications such as NSAIDs.
D.Elderly patients should be monitored closely for hypovolemia that present with gross hematuria.
Bibliography
Diagnosis, Evaluation and Follow-Up of Asymptomatic Microhematuria (AMH) in Adults. American Urologic Association. Published 2012. Reviewed and Validity Confirmed 2016.
Fatica, R., & Fowler, A. (2009, January). Hematuria. Cleveland Clinic for Continuing Education. Retrieved from https://www.auanet.org/guidelines/asymptomatic-microhematuria-(amh)-guideline#x2396
Lambert, M. (2013, May). AUA guideline addresses diagnosis, evaluation and follow-up of asymptomatic microhematuria. American Family Physician, 87(9), 649–653.