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
  •  
     
     

    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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