Hematuria differential diagnosis

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Steven C. Campbell, M.D., Ph.D. Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [1]

Overview

Gross hematuria(GH) must be distinguished from pigmenturia, which may be due to endogenous sources (e.g., bilirubin, myoglobin, porphyrins), foods ingested (e.g., beets and rhubarb), drugs (e.g., phenazopyridine), and simple dehydration. This distinction can be made easily by urinalysis with microscopy. Notably, myoglobinuria and other factors can cause false-positive chemical tests for hemoglobin, so urine microscopy is required to confirm the diagnosis of hematuria. GH also must be distinguished from vaginal bleeding in women, which usually can be achieved by obtaining a careful menstrual history, collecting the specimen when the patient is not having menstrual or gynecologic bleeding, or, if necessary, obtaining a catheterized specimen. GH may also be detected by the presence of blood spotting on the undergarments of incontinent patients. After ruling out vaginal bleeding and mimics of hematuria, a urologic source must be suspected.

Differential Diagnosis

CATEGORY	EXAMPLES	COMMON CLINICAL PRESENTATION AND RISK FACTORS
Neoplasm	Any	Male gender, Age older than 35 years, Past or current smoking history, Occupational or other exposure to chemicals or dyes (benzenes or aromatic amines), Analgesic abuse, History of gross hematuria, History of urologic disorder or disease, History of Irritative voiding symptoms, History of pelvic irradiation, History of chronic urinary tract infection, Exposure to known carcinogenic agents or chemotherapy such as alkylating agents, History of chronic indwelling foreign body
	Bladder cancer	Older age, male predominance, tobacco, occupational exposures, Irritative voiding symptoms
	Ureteral or renal pelvis cancer	Family history of early colon cancers or upper tract tumors, flank pain
	Renal cortical tumor	Family history of early kidney tumors, flank pain, flank mass
	Prostate cancer	Older age, family history, African-American
	Urethral cancer	Obstructive symptoms, pain, bloody discharge
Infection/inflammation	Any	History of infection
	Cystitis	Female predominance, dysuria
	Pyelonephritis	Fever, flank pain, diabetes, female predominance
	Urethritis	Exposure to sexually transmitted infections, urethral discharge, dysuria
	Tuberculosis	Travel to endemic areas
	Schistosomiasis	Travel to endemic areas
Calculus	Nephroureterolithiasis	Flank pain, family history, prior stone
	Bladder stones	Bladder outlet obstruction
Prostatic cause	Benign prostatic enlargement	Male, older age, obstructive symptoms
Medical renal disease	Any	Hypertension, azotemia, dysmorphic erythrocytes, cellular casts, proteinuria
	IgA nephropathy	Upper respiratory tract infection, gastroenteritis, synchronous association of pharyngitis, children
Congenital or acquired anatomic abnormality	Polycystic kidney disease	Family history of renal cystic disease
	Uretero-pelvic junction obstruction	History of UTI, stone, flank pain
	Ureteral stricture	History of surgery or radiation, flank pain, hydronephrosis; stranguria, spraying urine
	Urethral diverticulum	Discharge, dribbling, dyspareunia, history of UTI, female predominance
	Fistula	Pneumaturia, Fecaluria, abdominal pain, recurrent UTI, history of diverticulitis or colon cancer
Other	Exercise-induced hematuria	Recent vigorous exercise
	Endometriosis	Cyclic hematuria in a menstruating woman
	Hematologic or thrombotic disease	Family history of personal history of bleeding or thrombosis
	Papillary necrosis	African-American, sickle cell disease, diabetes, analgesic abuse
	Interstitial cystitis	Voiding symptoms

Differentiating Hemoglobinuria from Myoglobinuria

Centrifuse Result

Sediment Red

Supernatant Red

Hematuria

Dipstick heme

Negative

Positive

❑ Beeturia ❑ Phenazopyridine ❑ Porphyria ❑ Other

❑ Myoglobin ❑ Hemoglobin

Plasma color

Clear

Red

Myoglobinuria

Hemoglobinuria