Approach to Hematuria
Resident teaching rounds
Steve Radke :)
July 30, 2003
 Reference: Cohen et al. NEJM 348;23 June 5, 2003. P 2330-2338.
Hematuria
Clinical case
Classification
DDx
History, Physical
Investigations
Approach
Clinical Case
48 year old healthy female
5 rbc/hpf
Doctor….what’s going on?
Classification
Gross hematuria
Microscopic hematuria
>= 2 rbc/hpf
True
Pseudohematuria
menses
dyes
• beets, candy, juices
meds (e.g.. rifampin)
myoglobinuria, hemoglobinuria due to hemolysis
Classification
Glomerular
Nonglomerular
upper urinary tract
lower urinary tract
Diagnostic
DDx
(without the minutia)
 Origin
 Glomerular
 Nonglomerular
 Upper tract


Lower tract




< 50 yo
IgA nephropathy
> 50 yo
IgA nephropathy
nephrolithiasis
pyelonephritis
polycystic kidney
cystitis,
prostatitis,
benign bladder tumors
bladder ca
prostate ca
nephrolithiasis
renal-cell ca
polycystic kidney
urethritis
bladder ca
prostate ca
benign bladder
tumors
History
age
timing
urinary sxs
STI
flank pain
trauma, exercise
obstructive sxs
RFs: smoking, chemicals, radiation
Physical exam
B.P.
abdominal exam
DRE
Investigations - glomerular
Urine dip
protein, WBC, nitrites
Urine microscopy
rbc count
wbc count
red cell casts
If Red Cell Casts, Protein or Increased Cr
 ---> glomerular origin
Investigations
- upper tract
U/S
limited in detecting solid tumors <3cm
IVP
radiographic contrast die exposure
less sensitive and specific than U/S
sometimes can not differentiate solid vs cystic masses
CT
with and w/o contrast
preferred method
Investigations
- lower tract
Cystoscopy
Urine Cytology
less sensitive than cystoscopy, but
more specific
AM void samples x 3
The Approach
 Microscopic hematuria
 urine dipstick +ve


 Gross hematuria



repeat urine dipstick -ve w/u ends unless
(several days later)
RF for bladder ca

+ve
microscopy
red cell casts
glomerular hematuria
no red cell casts
nonglomerular hematuria
The Approach

glomerular hematuria


NO protein or
renal insufficiency




periodic medical follow-up
monitor for proteinuria or
renal insufficiency
(q 6-12 months)
+ve protein or
renal insufficiency
Nephrology referral
for renal biopsy
The Approach











nonglomerular hematuria
CT
(or U/S)
-ve
urine cytology
-ve
>= 50 or
RF for bladder Ca or
gross hematuria
cystoscopy
+ve
refer based
on lesion
+ve
cystoscopy
<50 and
no RF for bladder Ca
w/u ends (yearly urinalysis)
Take home messages
>50 yo R/o Ca
do casts
CT (not u/s or ivp)