Approach to a case of Hematuria

Department of Urology,
• Definition and Classification
• Cause
• Differential diagnosis
• Evaluation
• Management
 Classification
• Gross
• Microscopic
 Definition

 >3 RBC/HPF in adult

 >5 RBC/HPF in children
 Cause of hematuria
• Hemorrhagic cystitis
• Upper tract bleeding
• Hematuria from
prostatic origin
• Urethral bleeding
 Hemorrhagic cystitis

• Infectious • Chemical exposure

Bacterial Cyclophosphamide
Viral (especially BK virus, adenovirus) Ifosfamide
Fungal Busulfan
Parasitic Thiotepa
Trauma Temozolomide
External Aniline dye
Postsurgical (e.g., transurethral resection of Ether
the bladder) Nonoxynol-9 (accidental urethral insertion of
Malignancy vaginal
Bladder primary contraceptive
Bladder invasion from local/distant primary
Vascular malformation Radiation therapy history (e.g., prostate
cancer, cervical cancer)
Manifestation of systemic disease Medication induced
Amyloidosis Penicillin and derivatives (via immune
Rheumatoid arthritis reaction)
Crohn disease Bleomycin
Danazol
Tiaprofenic
Allopurinol
Phensuximide
Methenamine mandelate
Acetic acid
 Upper Urinary
Tract Bleeding
• Renal glomerular diseases • Vasculitis
IgA nephropathy (Berger disease) Henoch-Schönlein purpura
Thin basement membrane disease Wegener granulomatosis
Acute glomerulonephritis (e.g., Infection
poststreptococcal) Pyelonephritis
Lupus nephritis Xanthogranulomatous pyelonephritis
Hereditary nephritis (e.g., Alport Renal tuberculosis
syndrome) Fungal infection
Renal tubulointerstitial diseases Obstruction
Ureteropelvic junction obstruction
Papillary necrosis Ureteral stricture
Sickle cell nephropathy Nephrolithiasis
Analgesic nephropathy Malignancy
Polycystic kidney disease Renal cortical tumors (renal cell
Medullary sponge kidney carcinoma, benign tumors)
Upper tract urothelial carcinoma
• Fibroepithelial polyp
Vascular diseases
Renal arteriovenous malformations
(congenital, acquired)
Iliac arterio-ureteral fitula
Renal artery aneurysm (especially
ruptured)
Renal artery pseudoaneurysm
Renal artery and/or vein thrombosis
Hemangioma
Atheroembolic disease
Nutcracker syndrome
Loin-pain hematuria syndrome
Trauma
Blunt
Penetrating
Lateralizing essential hematuria
 Urethral bleeding
• MALE • FEMALE
Trauma Trauma
Blunt (straddle injury, kick to perineum) Blunt (pelvic fracture)
Penetrating (foreign body insertion, failed Penetrating (foreign body)
urethral Urethral diverticulum
catheterization) Urethral caruncle
Intercourse related (penile fracture, Urethritis
masturbation) Malignancy
Urethritis Calculus disease
Bacterial (gonococcal, nongonococcal)
Viral
Chemical
Autoimmune (Reiter syndrome)
Malignancy
Urothelial carcinoma
Squamous cell carcinoma (meatus/glans)
Condyloma
Calculus disease
 D/D of gross hematuria

– Hemoglobinuria
– Myoglobinuria
– Discoloration of urine
 EVALUATION

History
 Is the hematuria gross or microscopic?
 At what time during urination does the hematuria
occur (beginning
or end of stream or during entire stream)?
 Is the hematuria associated with pain?
 Is the patient passing clots?
 If the patient is passing clots, do the clots have a
specific shape?
Timing during micturition

Urethra

Trigone
Bladder neck
Posterior urethera

Bladder
Upper urinary
tract
Painful hematuria
Shape of clots
 Examinations

General examination- Vitals

Pallor ,
Diffuse bruise
Per abdomen – Suprapubic fullness or
mass
Fullness or mass in
lumber area
DRE- Hard /nodular prostate
 Investigations

Routine and microscopic examination

Urine cytology
Cystoscopy
Urinary tract imaging ( CT/IVU)
MICROSCOPY
Cystoscopy
IVP/CT scan
Management

Initial management
Catheterisation and irrigation with
saline/glycine
Clot evacuation
Fulgaration
Subsquent management
Treatment of cause
Thank You