Hematuria

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Definition
● Hematuria adalah kondisi urin berwarna merah (adanya darah)
● Such an alarming symptom

Cause
Varies according to:
● Patient Age
● Symptomatic or Asymptomatic
● The existence of risk factors for
malignancy
● The type: Gross or Microscopic
Classification and Timing
● Gross hematuria (GH) / frank hematuria / macrohematuria / visible hematuria : is
hematuria that can be seen with the naked eye
○ Initial : urethral source
○ Terminal : bladder trigone, bladder neck, prostate
○ Total : bladder or above
Differentiate from pigmenturia : due to endogenous source, food, drugs and
symple dehidration
differentiate from vaginal bleeding in women

● Microscopic hematuria (MH) : a lab diagnosis defined as the presence of RBCs

on microscopic exam of the urine not evident on visual inspection of the urine
Microscopic Hematuria
Ditemukan sel darah merah secara mikroskopik pada urin

● Prevalence 6.5%
● Predominance of males, older patients, smokers
● Categorized by presence or absence of associated symptoms
● Quantified accorfing to number of RBCs per HPF
Criteria for the Diagnosis of Microhematuria
Anamnesis : gejala, usia tua, riwayat keganasan pada keluarga, riwayat operasi,
riwayat ISK, RPD, riwayat pengobatan, riwayat kebiasaan (makan, rokok), riwayat
menstruasi (apabila perempuan), riwayat trauma

PF : nyeri ketok CVA, palpasi massa di pinggang, abdomen, suprapubik, uretra,

pembesaran prostat.

PP : imaging dan sistokopi

● AUA guideline :
○ 3 or more RBCs/HPF
○ A single positive urinalysis is sufficient to promt evaluation
Requirement for Microscopic Evaluation
● Urine dipstick test alone : insufficient to prompt an evaluation
● Must be comfirmed on urinalysis with microscopy

● False positive :
○ Conditions such as myoglobinuria
○ Specimen collected after prolonged recumbency or after vigorous
physical/sexual activity
○ Dilute urine (osmolality <308mOsm)
Causes
● Calculus (6.0%)
● Urethral stricture (1.4%)
● Malignancy (0.68-4.3%) : with
>25RBCs/HPF, GH, or RF for
malignancy
Selecting Patients for
Evaluation of
Microhematuria
● Found to have MH of
suspected benign cause 
must be substantiated by
clinical evidence 
further evaluated once
resolved
● Infection  confirm w/
culture  repeat urinalysis
after treatment
 Guideline-based
Evaluation of Patients
with Microhematuria

● Patients undergo a complete evaluation

● Anamnesis : urologic history,
surgeries, febrile UTIs, general
medical history, medication, smoking
history
● PE : genitourinary system
● Urine flow rate (susp urethral
stricture/BPH)
● Lab
Guideline-based Evaluation of Patients
with Microhematuria
● Cystoscopy : 35 years old or older and/or have RF for malignancy
● Upper tract imaging : recomended using CT urogram, if CT is contraindicated,
MR urogram is used
● Urine cytology : detection of high grade urothelial carcinoma
● MH with negative initial evaluation : resolve in 1/3 of patients over 3 months to
several years
● Negative work up  follow up urinalysis after 2 years  if confirmed resolution
of hematuria  release from care
● Persistent/reccurence asymptomatic MH  evaluation within 3-5 years for
symptoms or GH
Symptomatic Microscopic Hematuria
● DD equivakent to asymptomatic
● Higher risk for malignancy
● Cultured urinary infection : complete work up can be avoided
● Cystoscopy recomended by AUA regardless of age
● Cytologic exam : option in the setting of iritative voiding symptoms
Gross Hematuria
● 1 ml of blood in 1 liter of urine is
visible for the patients

● GH with absence antecendent

trauma/culture-documented UTI
 urine cytologic exam,
cystoscopy, upper tract imaging
(CT urogram)
Hemorrhagic cystitis
● Definition : intractable hematuria localizing to the
bladder
● Range in severity (quickly resolves to life-threatening
condition)
● Often elderly and infirm

Characteristic :
● Diffuse inflammation and bleeding from bladder mucosa
Hemorrhagic cystitis - Etiology
● Viral-induced : children and immunosuppressed adults. Most common by BK
virus (polyomavirus family), adenovirus type 11 and 35

● Exposure to oxazaphosphorine class of chemotherapeutic agents

(cyclophosphamide and ifosfamide)  2-mercaptoethane sulfonate (mesna) as
prophylaxis
Bladder toxicity : from renal excretion of the metabolite acrolein (produced
by the liver)  stimulate bladder mucosal sloughing  tissue edema/fibrosis

● Radiation therapy (predisposing factor) : damage vascular endothelium

 Management of
Hemorrhagic Cystitis
Hematuria from Prostatic Origin
● After complete GH evaluation (incl. Cytology, upper tract imaging, and
cystoscopy)  confirm no other source of hematuria
● Severity range from transient self-limiting episode to continuous bleeding 
obstuction of urinary flow & transfusion dependence
Hematuria from Prostatic Origin -
Etiology
● Most common due to :
○ BPH (men > 60 y.o) : increased prostatic vascularity  higher micovessel
density
○ prostate related infection (prostatitis) 2.5% : mechanism may be related to
inflammation
○ prostate cancer : often with bladder base/trigonal invasion
Urethral Bleeding (Urethrorrhagia)
● Definition : bleeding emanating from the urethra at a point distal to the bladder
neck, occurring separate from micturition

● History and PE :
○ blood at urethral meatus in the absence of volitional micturition,
○ initial hematuria, or
○ blood at the start of urination
 implies pathological processes distal external urinary sphincter
Urethral Bleeding -
Etiology
● Trauma : perineal or penile bruising accompanied by
hematoma
 retrograde urethrography is essential
○ Foreign body  imaging/cystoscopy
● Urethritis
 Urethral discharge on palpation  microscopy,
culture, swabs
● Urethral tumors : urothelial carcinoma, urethral
caruncle (common in post menopausal women)
Hematuria Originating from The Upper
Urinary Tract
Manifestation :
● Frequently asymptomatic
● Ureteral obstruction
● Clot colic
● Anemia
● Hemodynamic instability (rare)
● Total hematuria
● Bleeding throughout duration of urinary stream
● Worm like clots passed via urethra
 Hematuria
Originating from The
Upper Urinary Tract
Medical Renal Disease
● Glomerular diseases : constellation of acquired or inherited conditions in which
the glomeruli are damaged  loss of RBCs and protein
○ Sequelae : hematuria, hypoproteinemia with associated edema, GFR ↓
○ Urinary findings : RBC casts, dysmorphic RBCs, proteinuria
● Tubuointerstitial diseases : kidney diseases affecting structure in the kidney
outside glomerulus. Example :
○ Sickle cell nephrophaty
○ Analgesic nephrophaty

Diagnostic : percutaneous renal biopsy

Vascular Conditions Affecting the
Urinary Tract
Ureteroiliac artery fistula
● Predisposing factor : pelvic / vascular surgery, pelvic irradiation, extensive
ureteral mobilization, chronic ureteral stenting
● Management : vascular stenting

Renal arteriovenous malformations (AVMs)

● Diagnostic and therapeutic : arteriography with selective angioembolization
Vascular Conditions Affecting the Urinary Tract
Nutcracker syndrome : compression of the left renal vein between abdominal aorta
posteriorly and the superior mesenteric artery anteriorly
● Surgical approach : left renal vein transposition, superior mesenteric artery
transposition, nephrectomy
Lateralizing Essential Hematuria and the
Evaluation of Upper Urinary Tract
Bleeding
● definition: macroscopic hematuria cystoscopically localized to one side of the
urinary system

● Cystoscopy at the time of bleeding may allow lateralization

● Critical components of diagnostic ureteropyeloscopy (recomended for diagnostic

and potential therapeutic) :
○ Judicious use of guide wires
○ Low pressure irrigation
○ Systematic evaluation from all calices frpm a superior-to-inferior approach
Management
● Tangani syok dan perdarahan → stabil → anamnesis dan PF

● Bladder washout : Pakai kateter 3-way & irigasi normal saline → untuk
keluarkan bekuan darah. Apabila bekuan darah tidak dikeluarkan → retensi urin
tidak
● Bladder washout atau spoeling : Spoeling dilakukan secara manual dengan mendorong/m
menggunakan spuit 50cc. Masukkan 50cc normal saline secara perlahan ke buli enarik cairan
melalui kateter → lalu masukkan 50cc lagi → tarik kembali 50cc perlahan → secara tiba-
biasanya bekuan darah ikut keluar → dilakukan sampai tidak ada bekuan darah tiba
yang keluar lagi
Terimakasih