Hematuria resident survival guide

Hematuria Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Tayyaba Ali, M.D.[2]

Overview

Presence of >5 red blood cells (RBCs) per high-power microscopic field in the urine is called hematuria. It can have either benign or malignant etiology. Patients with hematuria could be asymptomatic. Therefore, all patients presenting with a single episode of haematuria require urgent investigation. Microscopic hematuria, or microhematuria (MH), is defined as the presence of RBC on microscopic examination of the urine not evident on visual inspection of the urine. The prevalence of MH among healthy participants in screening studies is 6.5% (95% confidence interval [CI] 3.4 to 12.2), with higher rates in studies with a predominance of males, older patients, and smokers.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Intraperitoneal bladder rupture

• Ureteroarterial fistula

• Hemorrhagic cystitis

• Heart failure

• Malignant hypertension

• Shock

Common Causes

Age <50 years	Age >50 years
Urinary tract infection Transient unexplained Stones Exercise Trauma Polycystic kidney disease	Urinary tract infection Transient unexplained Stones Benign prostatic hyperplasia Bladder cancer Renal carcinoma Prostate cancer

Diagnosis

The approach to diagnosis of hematuria is based on a step-wise testing strategy. Below is an algorithm summarising the identification and laboratory diagnosis of hematuria.

Seek proper history: ❑ Onset ❑ Progression ❑ Pain/burning on urination ❑ Fever ❑ Abdominal pain/flank pain ❑ Polyuria, frequency ❑ Straining during urination ❑ Nocturia ❑ Weak stream ❑ Dribbling

Examine the patient: ❑ Tachypnea ❑ Cold and clammy skin ❑ Hypotension ❑ HEENT signs: Conjunctival pallor Jaundice ❑ Cardiovascular exam: Tachycardia ❑ Abdominal exam: Costovertebral angle (CVA) tenderness ❑ skin exam: Look for rash ❑ Musculoskeletal exam: Joint pain

Initial workup for hematuria: ❑ Complete blood count (CBC) with differential ❑ Urinalysis, urine strain, and culture ❑ Blood urea nitrogen:creatinine (BUN:Cr) ❑ Ultrasound (U/S) and CT abdomen ❑ Cystoscopy

Urine dipstick positive for heme: Does microscopic urinalysis reveal >3 RBC/HPF?

Yes ❑ Consider hematuria

No ❑ Causes include free urinary hemoglobin (from intravascular hemolysis), or free urinary myoglobin (from rhabdomyolysis). In men, the presence of semen in the urine sample may produce a positive dipstick from heme.

Hematuria

Is acute onset unilateral flank pain present?

Yes Evaluate Nephrolithiasis

No Are any of the following present? ❑ Symptoms of urinary tract infection ❑ Urine WBCs ❑ Positive urine nitrite

No

Yes

Urine culture to exclude urinary tract infection

Negative

Positive

Is hematuria visible (pink, red, or brown urine color, or blood clots)?

Treat urinary tract infection ❑ Repeat urinalysis with microscopy in six weeks

Yes ❑ Gross Hematuria

No ❑ Microscopic Hematuria

Persistent hematuria ❑ Refer to hematuria (above)

No hematuria ❑ No further evaluation required

Gross Hematuria

Gross Hematuria

Are blood clots present/visible in the urine?

No Is there any evidence suggesting glomerular bleeding? ❑ Albuminuria (quantitative or semiquantitative) ❑ Acutely elevated serum creatinine ❑ Hypoalbuminemia ❑ Dysmorphic RBCs ❑ RBCs casts ❑ WBCs casts ❑ New or worsening hypertension ❑ New or worsening edema

Yes Order the following: ❑ Abdominopelvic CT with and without contrast for urography ❑ Urgent urologic referral

Yes

No

Refer patient to nephrology

Cause identified ❑ Treatment of the specific cause

Cause not identified ❑ Female of childbearing potential?

Yes ❑ Perform pregnancy test

No

Positive ❑ Perform ultrasound of kidneys and bladder. Avoid further evaluation, if possible, until after delivery.

Negative Order the following: ❑ Abdominopelvic Ct with and without contract for urography ❑ Urology referral for cystoscopy

Cause identified ❑ Treatment of the specific cause

Cause not identified ❑ Has the patient already had a nephrology evaluation?

No ❑ Refer patient to nephrology

Yes Annual urinalysis ❑ If negative for two years, stop ❑ If persistently positive for three years, repeat anatomic evaluation.

Microscopic Hematuria

Microscopic Hematuria

Do any of the following apply? ❑ Urine collected from a women during menses ❑ Urine collected shortly after vigorous exercise ❑ Urine collected shortly after acute trauma

No

Yes

Repeat urinalysis with microscopy at least six weeks later and in the absence of menses, vigorous exercise, and trauma

Persistent hematuria

No hematuria

Is there any evidence suggesting glomerular bleeding? ❑ Albuminuria (quantitative or semi-quantitative) ❑ Acutely elevated serum creatinine ❑ Hypoalbuminemia ❑ Dysmorphic RBCs ❑ RBC casts ❑ WBC casts ❑ New or worsening hypertension ❑ New or worsening edema

No further evaluation required

No

Yes ❑ Refer patient to nephrology

Cause not identified

Cause identified ❑ Treatment of the specific cause

Any of the following risk factors present? ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑

Treatment

The management of hematuria will depend on the underlying cause. Click on each disease shown below to see detail management for every cause of hematuria.

Initial hematuria: (Blood at beginning of micturition with subsequent clearing)	Terminal hematuria: (Blood seen at end of micturition after initial voiding of clear urine)	Total hematuria: (Blood visible throughout micturition)
❑ Urethritis ❑ Trauma (e.g, catheterization)	❑ Urothelial cancer ❑ Cystitis (Infectious/post radiation) ❑ Urotheliasis ❑ Benign prostatic hypertrophy ❑ Prostate cancer	❑ Renal mass (benign/malignant)' ❑ Glomerulonephritis ❑ Urolithiasis ❑ Polycystic kidney disease ❑ Pyelonephritis ❑ ❑ Urothelial cancer ❑ Trauma

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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