Hematuria resident survival guide

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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.

Common Causes

Age <50 years[1] Age >50 years[1]

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:

❑ Cardiovascular exam:

❑ 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
 
 
 
Cause not identified
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment of the specific cause
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Female of childbearing potential?

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

  1. 1.0 1.1 "www.surgeryjournal.co.uk".


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