Evaluation of Microscopic Hematuria

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Evaluation of Microscopic Hematuria

• Gil C. Grimes, MD
• December 17 2002

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Case

• HPI 48 yo male
• Right sided back pain for 3 weeks
• Some radiation to groin
• Recent increase in physical activity
• Tilling a field in an old tractor

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Case

• PMH
• Seasonal allergies
• Depression in remission
• PSH
• Tonsillectomy
• Social
• Tobacco one pack per day for 18 years
• Alcohol rare
• Drugs negative

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Case

• Meds
• No Rx
• No OTC
• No herbals or vitamins
• Fam Hx
• CAD, Fibromyalgia
• ROS
• No N/V/F/NS/Wt loss/Dysuria/Hematuria/ED

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Case

• Physical
• 118/66 T-97.9 P 84 Wt 202
• Gen- NAD WDWN
• CV- RRR w/o M/C/T, no Bruits
• Chest- CTAP
• ABD- NTND BS, No HSM
• BACK- no CVA tenderness, mild paraspinous
  tenderness at L5
• GU- normal circ male no hernia

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Case

• Labs
• UA 1.025, pH 6.0
• Trace ketone
• Bili positive
• Blood 2
• RBC 13-19
• WBC 0-1
• LE Neg
• Nitrite Neg
• Culture Negative

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What is Microscopic hematuria?

• 2-3 RBC per HPF or gt5 RBC
• Guideline settled on 3 RBC per HPF on 2 of 3
  specimens
• Hedge low risk patients
• Freshly voided clean catch midstream specimen (1)
• Dipstick
• Sensitivity 91-100
• Specificity 65-99 (2,3)
• Confirm all dipstick results with micropscopy

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Microscopy

• Chamber count
• Resuspension of sediment
• This is easier
• Semiquantitative
• Centrifuge 10 cc urine 5 minutes 2000 RPM
• Discard supernatent
• Resuspend in 0.5-1.0 mL of urine

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Risk factors (1)

• Smoking history
• Occupational exposure to chemicals or dyes
  (benzenes or aromatic amines)
• History of gross hematuria
• Age gt40 years
• History of urologic disorder or disease
• History of irritative voiding symptoms
• History of urinary tract infection
• Analgesic abuse
• History of pelvic irradiation

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Prevalence

• 9-18 individuals with hematuria
• Young Men 18-33 tested yearly for 15 years (4)
• 1000 patients
• 38.7 had one episode
• 16.1 had two episodes (in any 5 year period)
• One case of transitional cell cancer

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Causes

• Life threatening (1)
• Bladder, Renal cell, Prostate cancer
• Ureteral or Renal transitional cell carcinoma
• Metastatic cancer
• Uretheral and penile cancer
• Renal lymphoma
• Abdominal aortic aneruysm

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Causes

• Significant requiring treatment
• Renal, Ureteral, or Bladder calculus
• Vesicoureteral reflux
• Bacterial cystitis
• Ureteropelvic junction obstruction
• Renal parenchymal disease
• Symptomatic BPH
• Uretheral stricture or meatal stensosis
• Bladder papilloma
• Mycobacterial cystitis
• Renal artery stenosis
• Renal vein thrombosis

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Causes

• Significant requiring observation
• Radiation cystitis
• Bladder diverticulum
• Atrophic kidney
• Bladder neck contracture and phimosis
• Interstitial or eosinophilic cystitis
• Asymptomatic BPH and prostatitis
• Papillary necrosis
• Renal ateriovenous fistula
• Renal contusion
• Polycystic kidney disease
• Cystocoele, Ureterocele
• Neurogenic Bladder

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Insignificant

• Uretherotrigonitis
• Renal cyst
• Duplicated collecting system
• Prostatic calculus
• Bladder neck and Uretheral polyps
• Bladder varices or telangictasia
• Uretheral caruncle

• Pseudomembranous trigonitis
• Uretheritis
• Pelvic kidney
• Caliceal Diverticulum
• Exercise Hematuria
• Scarred kidney Trabeculated bladder

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Evaluation
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Evaluation
17
Evaluation
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Imaging

• Intravenous urography
• Considered by many to be best initial study for
  evaluation of urinary tract
• Widely available and most cost-efficient in most
  centers
• Limited sensitivity in detecting small renal
  masses
• Cannot distinguish solid from cystic masses
• further lesion characterization by
  ultrasonography, computed tomography or magnetic
  resonance imaging is necessary
• Better than ultrasonography for detection of
  transitional cell carcinoma in kidney or ureter

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Imaging

• Ultrasonography
• Excellent for detection and characterization of
  renal cysts
• Limitations in detection of small solid lesions
  (lt3 cm)

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Imaging

• Computed tomography
• Preferred modality for detection and
  characterization of solid renal masses
• Detection rate for renal masses comparable to
  that of magnetic resonance imaging, but more
  widely available and less expensive
• Best modality for evaluation of urinary stones,
  renal and perirenal infections, and associated
  complications
• Sensitivity of 94 to 98 for detection of renal
  stones, compared with 52 to 59 for intravenous
  urography and 19 for ultrasonography

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Followup
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Referances

1. Grossfield GD, Litwin MS, Wolf JS, Hricak H,
   Shuller CL, Agerter DC, Carroll PR Evaluation of
   asymptomatic microscopic hematuria in adults
   the American Urological Association best practice
   policy-part I Definition,detection, prevelence,
   and etiology Urology 57 599-603, 2001
2. Sutton JM, Evaluation of Hematuria in adults
   JAMA 2632475-2480, 1990
3. Corin HL, and Silverstein MD, Micropscopic
   hematuria Clin Lab Med 8601-910, 1988
4. Froom P, Ribak J, Benbassat J. Significance of
   microhemturia in young adults BMJ 28820-22, 1984
5. Grossfield GD, Litwin MS, Wolf JS, Hricak H,
   Shuller CL, Agerter DC, Carroll PR Evaluation of
   asymptomatic microscopic hematuria in adults
   the American Urological Association best practice
   policy-part Ii Patient evaluation, cytology,
   voided markers, imaging, cystoscopy, nephrology
   evaluation, and follow-up, Urology 57 604-610,
   2001