Hematuria resident survival guide

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Hematuria
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
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 could 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.[1][2][3][4]

Common Causes

Children[5] Age <50 years[6] Age >50 years[6]

Diagnosis

The approach to diagnosis of hematuria is based on a step-wise testing strategy. Below is an algorithm summarising the identification and laboratory diagnosis of hematuria. The algorithm developed and modified according to American Urological Evaluation (AUA) Guideline. [7][1]

 
 
 
 
 
 
 
 
 
 
 
 
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:

❑ Cardiovascular exam:

❑ 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 anemiaMyoglobinuria: 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[5]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Persistent hematuria
❑ Refer to hematuria (above)
 
No hematuria
❑ No further evaluation required


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 contract 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

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 contract 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 developed and modified according to 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. [1]

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

Do's

Don'ts

References

  1. 1.0 1.1 1.2 Avellino GJ, Bose S, Wang DS (June 2016). "Diagnosis and Management of Hematuria". Surg. Clin. North Am. 96 (3): 503–15. doi:10.1016/j.suc.2016.02.007. PMID 27261791.
  2. Sokolosky MC (August 2001). "Hematuria". Emerg. Med. Clin. North Am. 19 (3): 621–32. PMID 11554278.
  3. Silverman JA, Patel K, Hotston M (July 2016). "Tuberculosis, a rare cause of haematuria". BMJ Case Rep. 2016. doi:10.1136/bcr-2016-216428. PMID 27440856.
  4. Ogunjimi MA, Adetayo FO, Tijani KH, Jeje EA, Ogo CN, Osegbe DN (March 2011). "Gross haematuria among adult Nigerians: current trend". Niger Postgrad Med J. 18 (1): 30–3. PMID 21445110.
  5. 5.0 5.1 Amin, Nimisha; Zaritsky, Joshua J. (2011). "Hematuria": 258–261. doi:10.1016/B978-0-323-05405-8.00069-3.
  6. 6.0 6.1 "www.surgeryjournal.co.uk".
  7. "AUA Guidelines 2020: Microhematuria".
  8. 8.0 8.1 8.2 "Microhematuria: Asymptomatic - American Urological Association".
  9. "Medical Student Curriculum: Hematuria - American Urological Association".
  10. Sharp VJ, Barnes KT, Erickson BA (2013). "Assessment of asymptomatic microscopic hematuria in adults". Am Fam Physician. 88 (11): 747–54. PMID 24364522.

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