Hematuria resident survival guide

Hematuria Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Dos
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Tayyaba Ali, M.D.[2]

Synonyms and keywords: Blood in urine resident survival guide

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 can be asymptomatic. Therefore, all patients presenting with a single episode of hematuria 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.

• Intraperitoneal bladder rupture

• Ureteroarterial fistula

• Hemorrhagic cystitis

• Heart failure

• Malignant hypertension

• Shock

Common Causes

Children	Age <50 years	Age >50 years
Urinary tract infection Benign familial hematuria or Thin basement membrane disease IgA nephropathy Idiopathic hypercalciuria Transient unexplained	Urinary tract infection Transient unexplained Stones Exercise Trauma Polycystic kidney disease	Urinary tract infection Transient unexplained Stones Benign prostatic hyperplasia Bladder cancer Renal carcinoma Prostate cancer

Diagnosis

The approach to the diagnosis of hematuria is based on a step-wise testing strategy. Below is an algorithm summarizing the identification and laboratory diagnosis of hematuria. The algorithm was developed and modified according to the American Urological Evaluation (AUA) Guideline.

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: Conjunctival pallor Jaundice ❑ Cardiovascular exam: Tachycardia ❑ 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: ❑ Ingestion of certain foods: beets, blackberries, food coloring ❑ Ingestion of certain medications: Chloroquine, Ibuprofen, Iron, Sorbitol, Nitrofurantoin, Phenazopyridine, Urates or Rifampin (which often produces orange urine) ❑ Hemoglobinuria: often in the setting of hemolytic anemia ❑ Myoglobinuria: related to muscle damage (rhabdomyolysis), often after vigorous exercise or trauma ❑ Urinary tract infection: secondary to the action of bacterial peroxidases on the dipstick ❑ Delay in reading urine dipstick after submersion in urine ❑ Presence of semen in urine

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

No

Yes

Urine culture to exclude urinary tract infection

Negative

Positive

Is hematuria visible (pink, red, or brown urine color, or blood clots)?

Treat urinary tract infection ❑ Repeat urinalysis with microscopy in six weeks

Yes ❑ Gross Hematuria

No ❑ Microscopic Hematuria

Persistent hematuria ❑ Refer to hematuria (above)

No hematuria ❑ No further evaluation required

Gross Hematuria

Gross Hematuria

Are blood clots present/visible in the urine?

No Is there any evidence suggesting glomerular bleeding? ❑ Albuminuria (quantitative or semiquantitative) ❑ Acutely elevated serum creatinine ❑ Hypoalbuminemia ❑ Dysmorphic RBCs ❑ RBCs casts ❑ WBCs casts ❑ New or worsening hypertension ❑ New or worsening edema

Yes Order the following: ❑ Abdominopelvic CT with and without contrast for urography ❑ Urgent urologic referral

Yes

No

Refer patient to nephrology

Cause identified ❑ Treatment of the specific cause

Cause not identified ❑ Female of childbearing potential?

Yes ❑ Perform pregnancy test

No

Positive ❑ Perform ultrasound of kidneys and bladder. Avoid further evaluation, if possible, until after delivery.

Negative Order the following: ❑ Abdominopelvic CT with and without contrast for urography ❑ Urology referral for cystoscopy

Cause identified ❑ Treatment of the specific cause

Cause not identified ❑ Has the patient already had a nephrology evaluation?

No ❑ Refer patient to nephrology

Yes Annual urinalysis ❑ If negative for two years, stop ❑ If persistently positive for three years, repeat anatomic evaluation.

Microscopic Hematuria

Microscopic Hematuria

Do any of the following apply? ❑ Urine collected from a women during menses ❑ Urine collected shortly after vigorous exercise ❑ Urine collected shortly after acute trauma

No

Yes

Repeat urinalysis with microscopy at least six weeks later and in the absence of menses, vigorous exercise, and trauma

Persistent hematuria

No hematuria

Is there any evidence suggesting glomerular bleeding? ❑ Albuminuria (quantitative or semi-quantitative) ❑ Acutely elevated serum creatinine ❑ Hypoalbuminemia ❑ Dysmorphic RBCs ❑ RBC casts ❑ WBC casts ❑ New or worsening hypertension ❑ New or worsening edema

No further evaluation required

No

Yes ❑ Refer patient to nephrology

Cause not identified

Cause identified ❑ Treatment of the specific cause

Any of the following risk factors present? ❑ Age >35 years ❑ History of smoking ❑ Prior gross hematuria ❑ Occupational exposure to benzenes or aromatic amines ❑ History of heavy non-narcotic analgesic use ❑ History of urologic disorder or disease (e.g, BPH, nephrolithiasis) ❑ History of painful, frequent, or urgent urination ❑ History of chronic, recurrent urinary tract infection ❑ History of pelvic irradiation ❑ Prior use of alkylating agents such as cyclophosphamide ❑ Prior use of aristolochic acid

Yes

No

Female of childbearing potential?

Female of childbearing potential?

Yes ❑ Perform pregnancy test

No

No

Yes ❑ Order a pregnancy test

Positive ❑ Perform ultrasound of kidneys and bladder. Avoid further evaluation, if possible, until after delivery

No and Negative pregnancy test Order the following: ❑ Abdominopelvic Ct with and without contrast for urography ❑ Urology referral for cystoscopy

Negative ❑ Imaging exams and cystoscopy not required. However, some experts would perform ultrasound of kidneys and bladder or an alternate imaging exam with or without cystoscopy on such patients even in the absence of risk factors.

Positive ❑ Perform ultrasound of kidneys and bladder. Avoid further evaluation, if possible, until after delivery.

Cause identified ❑ Treatment of the specific cause

Cause not identified ❑ Has the patient already had a nephrology evaluation?

No ❑ Refer patient to nephrology

Yes Annual urinalysis ❑ If negative for two years, stop ❑ If persistently positive for three years, repeat anatomic evaluation.

This algorithm was developed and modified according to the American Urological Association (AUA) Guideline.

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

Dos

• The assessment of hematuria patient should include a careful history, physical examination, and laboratory examination to rule out benign causes of hematuria such as infection, menstruation, vigorous exercise, medical renal disease, viral illness, trauma, or recent urological procedures.
• At the initial evaluation, an estimate of renal function should be obtained (may include calculated eGFR, creatinine, and BUN) because the intrinsic renal disease may have implications for renal-related risk during the evaluation and management of patients with asymptomatic microscopic hematuria.
• Microhematuria that occurs in patients who are taking anticoagulants requires urologic evaluation and nephrologic evaluation regardless of the type or level of anti-coagulation therapy.
• A cystoscopy should be performed on all patients who present with risk factors for urinary tract malignancies (e.g., irritative voiding symptoms, current or past tobacco use, chemical exposures) regardless of age.
• For the urologic evaluation of asymptomatic microhematuria, a cystoscopy should be performed on all patients aged 35 years and older.
• Following an unrevealing workup for hematuria, a urinalysis should be checked annually. If the patient has two consecutive annual urinalyses negative for blood, then no further follow-up is required. Patients with persistent asymptomatic hematuria after a negative initial evaluation warrant repeat evaluation in 3-5 years, especially in those with risk factors for urologic malignancy.
• If a patient has microscopic hematuria in the presence of pyuria or bacteriuria, a urine culture should be obtained to rule out urinary tract infection. Culture-directed antibiotics should be administered, and a microscopic urinalysis should be repeated in six weeks to assess for the resolution of the hematuria. If the hematuria has resolved after the infection has cleared, no further workup is needed. If the hematuria persists, the diagnostic evaluation should commence.

Don'ts

• A positive urine dipstick does not define microscopic hematuria, and evaluation should be based solely on findings from the microscopic examination of urinary sediment and not on a urine dipstick reading.
• The presence of dysmorphic red blood cells, proteinuria, cellular casts, and/or renal insufficiency, or any other clinical indicator suspicious for renal parenchymal disease warrants concurrent nephrologic workup but does not preclude the need for urologic evaluation.
• The use of urine cytology and urine markers (NMP22, BTA-stat, and UroVysion FISH) is not recommended as a part of the routine evaluation of the asymptomatic microhematuria patient.
• Blue light cystoscopy should not be used in the evaluation of patients with asymptomatic microhematuria.
• If a patient with a history of persistent asymptomatic microhematuria has two consecutive negative annual urinalyses (one per year for two years from the time of initial evaluation or beyond), then no further urinalysis for the purpose of evaluation of asymptomatic microscopic hematuria is necessary.

References

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