Hematuria resident survival guide
| Hematuria Resident Survival Guide |
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| 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] |
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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:
❑ skin exam:
❑ Musculoskeletal exam:
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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:
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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) |
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| ❑ 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.