Approach to Hematuria

1
Approach to Hematuria

• Resident teaching rounds
• Steve Radke )
• July 30, 2003
• Reference Cohen et al. NEJM 34823 June 5,
  2003. P 2330-2338.

2
Hematuria

• Clinical case
• Classification
• DDx
• History, Physical
• Investigations
• Approach

3
Clinical Case

• 48 year old healthy female
• 5 rbc/hpf
• Doctor.whats going on?

4
Classification

• Gross hematuria
• Microscopic hematuria
• gt 2 rbc/hpf
• True
• Pseudohematuria
• menses
• dyes
• beets, candy, juices
• meds (e.g.. rifampin)
• myoglobinuria, hemoglobinuria due to hemolysis

5
Classification

• Glomerular
• Nonglomerular
• upper urinary tract
• lower urinary tract
• Diagnostic

6
DDx (without the minutia)

• Origin lt 50 yo gt 50 yo
• Glomerular IgA nephropathy IgA
  nephropathy
• Nonglomerular
• Upper tract nephrolithiasis
  nephrolithiasis
• pyelonephritis
  renal-cell ca
• polycystic kidney
  polycystic kidney
• Lower tract cystitis, prostatitis,
  urethritis
• benign bladder tumors
  bladder ca
• bladder ca
  prostate ca
• prostate ca
  benign bladder
• 
  tumors

7
History

• age
• timing
• urinary sxs
• STI
• flank pain
• trauma, exercise
• obstructive sxs
• RFs smoking, chemicals, radiation

8
Physical exam

• B.P.
• abdominal exam
• DRE

9
Investigations - glomerular

• Urine dip
• protein, WBC, nitrites
• Urine microscopy
• rbc count
• wbc count
• red cell casts
• If Red Cell Casts, Protein or Increased Cr
• ---gt glomerular origin

10
Investigations - upper tract

• U/S
• limited in detecting solid tumors lt3cm
• 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

11
Investigations - lower tract

• Cystoscopy
• Urine Cytology
• less sensitive than cystoscopy, but
• more specific
• AM void samples x 3

12
The Approach

• Microscopic hematuria
• urine dipstick ve
• repeat urine
  dipstick -ve w/u ends unless
• (several
  days later) RF for bladder ca
• ve
• Gross hematuria microscopy
• red cell casts
  no red cell casts
• glomerular hematuria
  nonglomerular hematuria

13
The Approach

• glomerular
  hematuria
• NO protein or
  ve protein or
• renal insufficiency
  renal insufficiency
• periodic medical follow-up
  Nephrology referral
• monitor for proteinuria or
  for renal biopsy
• renal insufficiency
• (q 6-12 months)

14
The Approach

• nonglomerular
  hematuria
• CT
  ve refer based
• (or U/S)
  on lesion
• 
  -ve
• urine
  cytology ve cystoscopy
• 
  -ve
• gt 50 or
  lt50 and
• RF for bladder Ca or
  no RF for bladder Ca
• gross hematuria
• cystoscopy
  w/u ends (yearly urinalysis)

15
Take home messages

• gt50 yo R/o Ca
• do casts
• CT (not u/s or ivp)