Hematuria

Background

• Make sure hematuria is not myoglobin or bleeding from non-urinary source
• Hematuria + pain suggests UTI
• Hematuria + no pain suggests malignancy, hyperplasia, or vascular cause

Common Causes

1. Younger pt
   1. UTI
   2. Nephrolithiasis
2. Older pt
   1. Neoplasm
   2. BPH
3. Peds
   1. Glomerulonephritis
4. Any age
   1. Schistosomiasis (most common cause worldwide)

Clinical Features

Types of hematuria

1. Initial hematuria
   1. Blood at beginning of micturition w/ subsequent clearing
   2. Suggests urethral disease
2. Intervoid hematuria
   1. Blood between voiding only while voided urine is clear
   2. Suggests lesions at distal urethra or meatus
3. Total hematuria
   1. Blood visible throughout micturition
   2. Suggests disease of kidneys, ureters, or bladder
4. Terminal hematuria
   1. Blood seen at end of micturition after initial voiding of clear urine
   2. Suggests disease at bladder neck or prostatic urethra
5. Gross hematuria
   1. Indicates lower tract cause
6. Microscopic hematuria
   1. Tends to occur with kidney disease
7. Brown urine w/ RBC casts and proteinuria
   1. Suggests glomerular source
8. Clotted blood
   1. Indicates source below kidneys

Diagnosis

• Labs
  • UA
    • Microscopic hematuria a/w proteinuria requires further investigation (as oupt)
      • Suggests significant glomerular disease
• Imaging
  • CT
    • Renal tumors, obstructions, stones
    • Assessment of renal function (normal enhancement and excretion of contrast)
  • US
    • Obstruction, hydronephrosis, AAA

DDx

1. Urologic (lower tract)
   1. Any location
      1. Iatrogenic/postprocedure
      2. Trauma
      3. Infection
      4. Stones/calculi
      5. Erosion or mechanical obstruction by tumor
   2. Ureter(s)
      1. Dilatation of stricture
   3. Bladder
      1. Transitional cell carcinoma
      2. Vascular lesions or malformations
      3. Chemical or radiation cystitis
   4. Prostate
      1. Benign prostatic hypertrophy
      2. Prostatitis
   5. Urethra
      1. Stricture
      2. Diverticulosis
      3. Foreign body
      4. Endometriosis (cyclic hematuria with menstrual pain)
2. Renal (upper tract)
   1. Glomerular
      1. Glomerulonephritis
      2. Immunoglobulin A nephropathy (Berger disease)
      3. Lupus nephritis
      4. Hereditary nephritis (Alport syndrome)
      5. Toxemia of pregnancy
      6. Serum sickness
      7. Erythema multiforme
   2. Nonglomerular
      1. Interstitial nephritis
      2. Pyelonephritis
      3. Papillary necrosis: sickle cell disease, diabetes, NSAID use
      4. Vascular: arteriovenous malformations, emboli, aortocaval fistula
      5. Malignancy
      6. Polycystic kidney disease
      7. Medullary sponge disease
      8. Tuberculosis
      9. Renal trauma
3. Hematologic
   1. Primary coagulopathy (e.g., hemophilia)
   2. Pharmacologic anticoagulation
   3. Sickle cell disease
4. Miscellaneous
   1. Eroding abdominal aortic aneurysm
   2. Malignant hypertension
   3. Loin pain–hematuria syndrome
   4. Renal vein thrombosis
   5. Exercise-induced hematuria
   6. Cantharidin (Spanish fly) poisoning
   7. Stings/bites by insects/reptiles having venom with anticoagulant properties

Treatment

• Treat underlying cause
• Gross hematuria
  • Often associated w/ intravesical clot formation and bladder outlet obstruction
    • Use triple-lumen urinary drainage catheter w/ intermittent or cont bladder irrigation
      • Adequate urinary drainage must be ensured; otherwise consult urology

Disposition

• Outpatient management appropriate if:
  • Hemodynamically stable without life-threatening cause of hematuria
  • Able to tolerate oral fluids, abx, and analgesics as indicated
  • No significant anemia or acute renal insufficiency
• Pts <40 yr: refer to primary care physician for repeat UA w/in 2wk
• Pts >40 yr w/ risk factor for urologic cancer: refer to urologist w/in 2wk
  • Risk factors:
    • Smoking history
    • Occupational exposure to chemicals or dyes
    • History of gross hematuria
    • Previous urologic history
    • History of recurrent UTI
    • Analgesic abuse
    • History of pelvic irradiation
    • Cyclophosphamide use
    • Pregnancy
    • Known malignancy
    • Sickle cell disease
    • Proteinuria
    • Renal insufficiency
• Admit:
  • Intractable pain
  • Intolerance of oral fluids and medications
  • Bladder outlet obstruction
  • Suspected or newly diagnosed glomerulonephritis
    • High risk of developing complications (pulm edema, vol overload, HTN emergency)
  • Pregnant women (hematuria can accompany preeclampsia, pyelo or obstructing stone)

See Also

Hematuria (Peds) DDx

Source

Tintinalli