Hematuria differential diagnosis
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Steven C. Campbell, M.D., Ph.D. Associate Editor(s)-in-Chief: Omer Kamal, M.D.[1], Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [2]
Overview
Gross hematuria(GH) must be distinguished from pigmenturia, which may be due to endogenous sources (e.g., bilirubin, myoglobin,and porphyrins), foods ingested (e.g., beets and rhubarb), drugs (e.g., phenazopyridine), and simple dehydration. This distinction can be made easily by urinalysis with microscopy. Notably, myoglobinuria and other factors can cause false-positive chemical tests for hemoglobin, so urine microscopy is required to confirm the diagnosis of hematuria. GH also must be distinguished from vaginal bleeding in women, which usually can be achieved by obtaining a careful menstrual history, collecting the specimen when the patient is not having menstrual or gynecologic bleeding, or, if necessary, obtaining a catheterized specimen. GH may also be detected by the presence of blood spotting on the undergarments of incontinent patients. After ruling out vaginal bleeding and mimics of hematuria, a urologic source must be suspected.
Differential Diagnosis
Hematuria should be differentiated from other disease which mimic hematuria especially hemoglobinuria and myoglobinuria which are dipstick positive but negative for microscopy.
Hematuria differential diagnosis
Differentiating the diseases that can cause hematuria:
Diseases | Clinical manifestations | Para-clinical findings | Gold standard | Additional findings | ||||||||||||||
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Symptoms | Physical examination | |||||||||||||||||
Lab Findings | Imaging | Histopathology | ||||||||||||||||
Low back pain | Fever | Nausea/
Vomiting |
Urinary symptoms | Hypertension | Pitting edema | Other | Ultrasonography | CT scan | Other | |||||||||
Dysuria | Frequency | Oliguria | Light microscopy | Immunoflourescence pattern | ||||||||||||||
Glomerular diseases | IgA nephropathy (Berger nephropathy) | + | - | - | - | + | + | + | - | - | - | - |
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Biopsy | - | |
Hereditary nephritis (Alport syndrome) | - | - | - | - | - | - | + | - |
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- |
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- |
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- | ||
Poststreptococcal glomerulonephritis | +/- | + | - | - | + | + | + | + |
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Renal Biopsy
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- | - |
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Biopsy | - | |
Focal segmental glomerular sclerosis | - | - | - | - | - | - | + | + |
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- | - |
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Biopsy | - | |
Rapidly progressive glomerulonephritis | + | + | + | - | - | - | + | - |
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- | - | - | Diffuse, proliferative, necrotizing glomerulonephritis with crescent formation | - | Biospy | 80% of patients have ANCA-positive microscopic polyangiitis | |
Lupus nephritis | - | + | - | - | - | - | + | + |
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- | - | - | - | - | Biopsy | - | |
Fabry disease | - | - | - | - | - | - | + | + | - |
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- | - | - | Non-specific+/- nephrotic picture | - | - | - | |
Disease | Low back pain | Fever | Nausea/
Vomiting |
Dysuria | Frequency | Oliguria | Hypertension | Pitting edema | Other | Lab Findings | Ultrasonography | CT scan | Other | Light microscopy | Immunoflourescence pattern | Gold standard | Additional findings | |
Tubulointerstitial diseases | + | + | + | – | – | – | – | – | Rash | N | Rules out obstruction , if any | – |
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– | Renal biopsy | |||
Nephrolithiasis | + | ± | + | ± | ± | ± | – | – |
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Reflux nephropathy (hydronephrosis) | + | + | - | - | - | - | - | + | ||||||||||
Malignancy | Renal cell carcinoma (RCC) | – | ||||||||||||||||
Nephroblastoma | ||||||||||||||||||
Transitional cell carcinoma (TCC) | ||||||||||||||||||
Prostate cancer | ||||||||||||||||||
Disease | Low back pain | Fever | Nausea/
Vomiting |
Dysuria | Frequency | Oliguria | Hypertension | Pitting edema | Other | Lab Findings | Ultrasonography | CT scan | Other | Light microscopy | Immunoflourescence pattern | Gold standard | Additional findings | |
Familial diseases | Polycystic kidney disease | + | - | - | - | - | - | + | + |
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Genetic testing demonstrates: |
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Ultrasound | ||
Vascular diseases | Renal vein thrombosis | + | + | + | - | - | - | - | - |
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Polyarteritis nodosa | - | -/+ | - | - | - | + | + | - |
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Wegner's granulomatosis polyangiitis | - | - | - | - | - | - | + | + |
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- | CT chest | +C ANCA antibodies |
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- | Biopsy | ||
Henoch-Schönlein purpura | ||||||||||||||||||
Disease | Low back pain | Fever | Nausea/
Vomiting |
Dysuria | Frequency | Oliguria | Hypertension | Pitting edema | Other | Lab Findings | Ultrasonography | CT scan | Other | Light microscopy | Immunoflourescence pattern | Gold standard | Additional findings | |
Lower urinary tract diseases | Benign prostatic hyperplasia | +/- | - | - | + | + | - | - | - |
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Urolithiasis | + | +/- | + | + | ||||||||||||||
Interstitial cystitis | ||||||||||||||||||
Radiogenic cystitis | ||||||||||||||||||
Systemic diseases | Coagulopathy (hemophilia) | |||||||||||||||||
Sickle cell anemia | ||||||||||||||||||
Abdominal aortic aneurysm | ||||||||||||||||||
Lymphomas | ||||||||||||||||||
Multiple myeloma | ||||||||||||||||||
Disease | Low back pain | Fever | Nausea/
Vomiting |
Dysuria | Frequency | Oliguria | Hypertension | Pitting edema | Other | Lab Findings | Ultrasonography | CT scan | Other | Light microscopy | Immunoflourescence pattern | Gold standard | Additional findings | |
Infectious diseases | Pyelonephritis | + | + | + | + | + | + | - | - |
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Contrast nephrograms
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- | ||||
Cystitis | - | - | - | + | + | + | - | - |
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MRI
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Prostatitis | - | + | - | + | + | + | - | - |
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Urethritis | -/- | + | - | + | + | + | - | - |
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- |
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- | |||||
Epididymitis | -/+ | + | + | - | - | - | - | - | ||||||||||
Urogenital trauma | Inserted bladder or ureteral catheters | |||||||||||||||||
Disease | Low back pain | Fever | Nausea/
Vomiting |
Dysuria | Frequency | Oliguria | Hypertension | Pitting edema | Other | Lab Findings | Ultrasonography | CT scan | Other | Light microscopy | Immunoflourescence pattern | Gold standard | Additional findings | |
Hemoglobinuria | Autoimmune hemolytic anemia | |||||||||||||||||
Microangiopathic hemolytic anemia | ||||||||||||||||||
Thrombotic thrombocytopenic purpura | ||||||||||||||||||
Paroxysmal nocturnal hemoglobinuria |