Hematuria 1

Hematuria

Hematuria may be a sign of urinary tract malignancy or renal parenchymal disease.

Up to 18% of normal persons excrete red blood cells into the urine, averaging 2 million
RBCs per 24 hours or 2 RBC's per high-power field (HPF).
I. Pathophysiology of Hematuria

A. Improper collection and improper analysis can yield false-positive results.

Exercise or jogging can cause an increase in RBC excretion, and hematuria

may be intermittent.

B. Dipstick testing detects hemoglobin and myoglobin; microscopic examination

of the urinary sediment is required before a diagnosis of hematuria can be

made.

II. Clinical Evaluation of Hematuria

A. The patient should be asked about frequency, dysuria, pain, colic, fever,

fatigue, anorexia, abdominal, flank, or perineal pain. Exercise, jogging,

menstruation, on a history of kidney stones should be sought.

B. The patient should be examined for hypertension, edema, rash, heart

murmurs, or abdominal masses (renal tumor, hydronephrosis from

obstruction). Costovertebral-angle tenderness may be a sign of renal calculus

or pyelonephritis.
C. Genitourinary examination may reveal a foreign body in the penile urethra or

cervical carcinoma invading the urinary tract. Prostatitis, carcinoma, or benign

prostatic hyperplasia may be found.

III. Laboratory Evaluation

A. At least one of the following criteria should be met before initiating a workup

for hematuria.
1. More than 3 RBC's/HPF on two of three properly collected clean-catch
specimens (abstain from exercise for 48 hours before sampling; not during

menses).
2. One episode of gross hematuria.
2 Hematuria

3. One episode of high-grade microhematuria (>100 RBCs HPF)

B. A properly collected, freshly voided specimen should be examined for red
blood cell morphology; the character of the sediment and the presence of
proteinuria should be determined.
C. RBC casts are pathognomonic of glomerulonephritis. WBC casts and granular
casts are indicative of pyelonephritis.

D. Urine culture should be completed to rule out urinary tract infection, which may

cause hematuria.

E. Serum blood urea nitrogen and creatinine levels should be evaluated to rule
out renal failure. Impaired renal function is seen more commonly with medical

hematuria.

F. Fasting blood glucose levels should be obtained to rule out diabetes; a

complete blood count should be obtained to assess severity of blood loss and
to evaluate indications of infection.

G. Serum coagulation parameters should be measured to screen for

coagulopathy. Skin tests for tuberculosis should be completed if risk factors

are present. A sickle cell prep is recommended for all black patients.
IV. Classification of Hematuria

A. Medical hematuria is caused by a glomerular lesion. Plasma proteins are

present in the urine out of proportion to the amount of hematuria. It is

characterized by glomerular RBCs, which are distorted with crenated

membranes and an uneven hemoglobin distribution casts. Microscopic

hematuria and a urine dipstick test of 2+ protein is more likely to have a

medical cause.
B. Urologic hematuria is caused by urologic lesions, such as a urinary stone or

bladder cancer. It is characterized by minimal proteinuria with plasma protein

in the urine proportional to the amount of whole blood added. Non-glomerular
RBCs (disk shaped) and an absence of casts are characteristic.
V. Diagnostic Evaluation of Medical Hematuria
 Hematuria 3

A. Renal Ultrasound. Evaluate kidney size and rule out hydronephrosis or cystic

disease.
B. 24-hour Urine. Creatinine, creatinine clearance and protein to assess renal

failure.
C. Immunologic Studies. Third and fourth complement components, antinuclear

antibodies, cryoglobulins, anti-basement membrane antibodies; serum and

urine protein electrophoresis (to rule out IgA nephropathy).

D. Audiogram: If a family history of Alport syndrome is present.

E. Skin biopsy can reveal dermal capillary deposits of IgA in 80% of patients with

Berger's disease (IgA nephropathy); the most common cause of

microhematuria in young adults.

VI. Diagnostic Evaluation of Urologic Hematuria

A. Intravenous pyelography is the best screening test for upper tract lesions if the

serum creatinine is normal. It is usually contraindicated if renal insufficiency. If

renal insufficiency is present, renal ultrasound and cystoscopy with retrograde

pyelogram should be used to search for etiologic causes of hematuria such as

stones or malignancy. If the IVP Is normal, cystoscopy with washings for cytology

may reveal the cause of bleeding.

B. Other Tests

1. Lesions in the kidney visualized on IVP can be evaluated by renal ultrasound

to assess cystic or solid character. CT-guided aspiration of cysts may be

considered.

2. Filling defects in the ureter should be evaluated by retrograde pyelogram and

ureteral washings.
VII. Idiopathic Hematuria

A. Idiopathic hematuria is a diagnosis of exclusion. Five to 10% of patients with

significant hematuria will have no diagnosis.
B. Suspected urologic hematuria with a negative initial workup should be followed

every 6-12 months with a urinalysis and urine cytology. An IVP should be done
every 2-3 years.
C. Renal function and proteinuria should be monitored. If renal function declines
4 Hematuria

or if proteinuria exceeds 1 gm/day, renal biopsy is indicated. §