Definition
A.Hematuria is blood in the urine. Hematuria is a symptom of an underlying disease/condition; however, routine screening is not recommended. Microscopic hematuria is defined as greater than three red blood cells (RBCs) per high-power microscope field (HPF) in urinary sediment clean-catch midstream urine specimens.
B.Asymptomatic microscopic hematuria can range from minor findings that do not require treatment to highly significant, life-threatening lesions. Microscopic hematuria is an incidental finding. The AUA recommends an appropriate renal or urologic evaluation with asymptomatic microscopic hematuria for patients who are at risk for urologic disease or primary renal disease.
C.If the excretion rate exceeds one million RBCs, macroscopic or gross hematuria is noted. Gross hematuria (macroscopic hematuria) is suspected when red or brown urine is present. Color change does not necessarily reflect the degree of blood loss. Glomerulonephritis is associated with brown urine, whereas bleeding from the lower urinary tract is suggested by pink or red urine. Gross hematuria with passage of clots almost always indicates a lower urinary tract source.
Incidence
A.The prevalence of asymptomatic hematuria is from 1% to 20% of the general population. Less than 3% excrete 10 RBC/HPF. Every disease of the genitourinary (GU) tract can produce hematuria.
Pathogenesis
A.Prerenal pathology:
1.Coagulopathy: Hemophilia or idiopathic thrombocytopenia purpura (ITP).
2.Drugs:
a.Anticoagulants (warfarin or dabigatran).
b.Aspirin.
3.Sickle cell disease or trait.
4.Collagen vascular disease; lupus.
5.Wilms’ tumor.
B.Renal pathology:
1.Nonglomerular pathology:
a.Pyelonephritis.
b.Polycystic kidney disease.
c.Granulomatous disease; TB.
d.Malignant neoplasm.
e.Congenital and vascular anomalies.
2.Glomerular pathology:
a.Glomerulonephritis.
b.Berger’s disease.
c.Lupus nephritis.
d.Benign familial hematuria.
e.Vascular abnormalities; vasculitis.
f.Alport’s syndrome; familial nephritis.
C.Postrenal pathology:
1.Renal calculi.
2.Ureteritis.
3.Cystitis.
4.Prostatitis.
5.Benign prostatic hypertrophy (BPH).
6.Epididymitis.
7.Urethritis.
8.Malignant neoplasm.
D.False hematuria:
1.Vaginal bleeding.
2.Recent circumcision.
3.Pigmentation:
a.Food: Beets, blackberries.
b.Medications: Quinine sulfate, phenazopyridine, and rifampin.
E.Other causes:
1.Trauma.
2.Strenuous exercise (marathons).
3.Fever.
Predisposing Factors
A.See previous section, Pathogenesis.
B.Risk factors for malignancy:
1.Age older than 35.
2.Smoking (current use or past history).
3.Chemical exposure (cyclophosphamide, benzenes, aromatic amines).
4.History of pelvic irradiation.
5.Chronic analgesic abuse.
6.Chronic urinary tract infections (UTIs).
7.Prior urologic disease or treatment.
8.Male.
Common Complaints
A.Pink or red urine (clots may be present) or brown cola-colored urine on toilet tissue is the common complaint.
Other Signs and Symptoms
A.Pain may or may not be present. Colicky flank pain radiating to the groin suggests a kidney stone. Significant flank pain of renal colic is usually secondary to renal calculi, but may occasionally be associated with passage of clots.
B.Frequency, dysuria, urgency, and suprapubic pain occur with cystitis and inflammatory lesions of the lower urinary tract.
C.Dull flank pain with fever and chills may accompany pyelonephritis.
D.Hesitancy and dribbling of the urine suggest BPH.
Subjective Data
A.Elicit onset, duration, and occurrence (beginning, ending, or during voiding) of hematuria. Describe the color and amount: Is it pink on tissue
or bright red in the toilet and tissue?
B.Question the patient regarding past medical history of renal disease, systemic disease such as lupus, or sickle cell disease.
C.Review all medications including over-the-counter (OTC) and herbal products. Evaluate specifically for the use of aspirin, ibuprofen, warfarin (Coumadin), and laxatives containing phenolphthalein. Rifampin and phenazopyridine HCl (Pyridium) can change the color of urine to orange or red.
D.Review other symptoms, such as dysuria, fever, chills, pain, and hesitancy with voiding.
E.Female patients:
1.Establish whether the blood was urinary or from the vagina (after intercourse or during menstruation).
2.Is the patient postpartum?
3.Is there a history of endometriosis?
F.Does the patient bruise easily? Does the patient have bleeding noted when flossing teeth or with brushing?
G.Has the patient had a recent bout of pharyngitis with a rash, hematuria, edema, or hypertension (HTN) (glomerulonephritis)?
H.Has he or she had any recent trauma, car accident, or strenuous exercise (e.g., running a marathon)?
I.Does the patient know if he or she has had any exposure to tuberculosis (TB)?
J.Is there any family history of kidney disease, stones, and familial nephritis?
K.Does the patient have any current outbreaks of herpes or other sexually transmitted infections (STIs)?
L.Review the patient’s smoking history.
M.Review occupation exposure to chemicals or dyes (benzenes or aromatic amines).
N.Review intake of foods such as beets and blackberries.
O.Does the male patient have any hesitancy and dribbling (signs of prostatic obstruction)?
P.Evaluate if there is rectal bleeding from hemorrhoids for strain with a bowel movement (BM).
Physical Examination
A.Check temperature, BP, and weight in the presence of recent weight gain or edema.
B.Male or female patients:
1.Inspect:
a.Inspect mouth: Check tonsils for enlargement and check gums for petechiae.
b.Examine skin for signs of bleeding or bruises and pallor.
c.Examine for edema.
2.Palpate:
a.Check the back and abdomen for costovertebral angle (CVA) tenderness.
b.Check the abdomen for masses, urinary distension, tenderness, and organomegaly.
c.Palpate groin lymph nodes for enlargement.
3.Auscultate:
a.Heart and lungs.
b.For abdominal bruits.
C.Female patients:
1.Inspect:
a.Direct visualization of the external genitalia for inflammation, ulcerations, nodules, lesions, and hemorrhoids.
b.Ask the patient to bear down to check for cystocele and rectocele.
c.Speculum exam: Observe for atrophic vaginitis, torn tissue, discharge, and friable cervix.
2.Palpate:
a.Milk urethra for discharge.
b.Bimanual exam: Check for cervical motion tenderness and adnexal masses.
c.Rectal exam: Check for the presence of hemorrhoids.
D.Male patients:
1.Inspect:
a.Direct visualization of the genitals; check the urethral meatus for discharge.
b.Retract the foreskin (if present) and assess for hygiene and smegma. Check the shaft of the penis, glans, and prepuce for lesions or urethral meatal erosion.
2.Palpate:
a.Palpate the testes and epididymides for inflammation, tenderness, and masses; palpate the scrotum for hydrocele or varicocele.
b.Check the inguinal and femoral areas for bulges and hernias; have the patient bear down and cough, and reexamine patient.
c.Rectal exam:
i.Check for swollen or tender prostate.
ii.Check for the presence of hemorrhoids.
Diagnostic Tests
A.Urinalysis:
1.The initial step in the evaluation of patients with red urine is to centrifuge the urine specimen to see if the red or brown color is in the urine sediment or supernatant.
2.If the supernatant is red to brown, test for heme (hemoglobin (Hgb) or myoglobin) with a urine dipstick. Semen is in urine after ejaculation and may cause a positive heme reaction on the dipstick.
3.A positive dipstick must always be confirmed with a microscopic examination.
4.Urine culture and sensitivity.
5.Urine cytology.
B.After the physical exam and consultation, consider the following:
1.Complete blood count (CBC) with differential.
2.Blood urea nitrogen (BUN).
3.Creatinine.
4.Prothrombin time (PT), partial thromboplastin time (PTT) platelet count, and bleeding time (if indicated).
5.Sickle cell testing (if indicated).
6.The Nickel premassage and postmassage 2-glass test for the male patient (see Section II: Procedure Prostatic Massage Technique: 2-Glass Test
).
7.Collect 24-hour urine for calcium, uric acid, protein, and creatinine. Follow with a 24-hour urine collection for creatinine and protein to assess renal function and quantitatively assess the degree of proteinuria.
8.Culture for gonorrhea and chlamydia.
9.Urine culture for acid-fast bacillus.
10.CT urography (CTU) is considered the preferred initial imaging in most patients for any unexplained persistent hematuria. CT is considered the best imaging modality for the evaluation of urinary stones, renal and perirenal infections, and associated complications. Intravenous pyelogram (IVP) and ultrasound are not as sensitive in the evaluation.
11.Cystoscopy: The combination of a CTU and the cystoscopy provides a complete evaluation.
12.A CT scan of the abdomen or pelvis should be considered with a history of trauma to determine the source of blood.
C.Based on history, consider the following tests:
1.Strep testing to detect poststreptococcal glomerulonephritis.
2.Antinuclear antibody (ANA) test to detect lupus nephritis.
D.Urological referral testing includes:
1.CTU and cystoscopy.
2.MRI if a mass is suspected.
3.Renal biopsy.
Differential Diagnoses
A.See section on Pathogenesis
for differential diagnoses.
Plan
A.General interventions:
1.Investigate and diagnose cause(s). Only a limited workup (electrolytes, CBC) is needed in patients younger than 35 with normal physical exam.
2.Patients older than 35 need a detailed investigation and referral.
3.Microhematuria with patients on an anticoagulant requires a urologic/nephrology workup regardless of the type or level of anticoagulation.
4.Repeat urinalysis in 2 weeks.