Approach to Hematuria

Resident teaching rounds

Steve Radke :)

July 30, 2003

Reference: Cohen et al. NEJM 348;23 June 5, 2003. P 2330-2338.

Hematuria

Clinical caseClassificationDDxHistory, PhysicalInvestigationsApproach

Clinical Case

48 year old healthy female5 rbc/hpf

Doctor….what’s going on?

ClassificationGross hematuriaMicroscopic hematuria

>= 2 rbc/hpfTruePseudohematuria

mensesdyes

• beets, candy, juices

meds (e.g.. rifampin)myoglobinuria, hemoglobinuria due to hemolysis

Classification

GlomerularNonglomerular

upper urinary tract lower urinary tract

Diagnostic

DDx (without the minutia)

Origin < 50 yo > 50 yo Glomerular IgA nephropathy IgA nephropathy Nonglomerular Upper tract nephrolithiasis nephrolithiasis

pyelonephritis renal-cell ca polycystic kidney polycystic kidney Lower tract cystitis, prostatitis, urethritis benign bladder tumors bladder ca bladder ca prostate ca prostate ca benign bladder tumors

History

agetimingurinary sxsSTIflank paintrauma, exerciseobstructive sxsRFs: smoking, chemicals, radiation

Physical exam

B.P.abdominal examDRE

Investigations - glomerular

Urine dip protein, WBC, nitrites

Urine microscopy rbc count wbc count red cell casts

If Red Cell Casts, Protein or Increased Cr ---> glomerular origin

Investigations - upper tract

U/Slimited in detecting solid tumors <3cm

IVPradiographic contrast die exposureless sensitive and specific than U/Ssometimes can not differentiate solid vs cystic

masses

CTwith and w/o contrastpreferred method

Investigations - lower tract

Cystoscopy

Urine Cytology less sensitive than cystoscopy, but more specific AM void samples x 3

The Approach Microscopic hematuria

urine dipstick +ve

repeat urine dipstick -ve w/u ends unless

(several days later) RF for bladder ca

+ve Gross hematuria microscopy

red cell casts no red cell casts glomerular hematuria nonglomerular

hematuria

The Approach

glomerular hematuria

NO protein or +ve protein or renal insufficiency renal insufficiency

periodic medical follow-up Nephrology referral monitor for proteinuria or for renal biopsy renal insufficiency (q 6-12 months)

The Approach

nonglomerular hematuria

CT +ve refer based (or U/S) on lesion -ve urine cytology +ve cystoscopy -ve >= 50 or <50 and RF for bladder Ca or no RF for bladder Ca gross hematuria

cystoscopy w/u ends (yearly urinalysis)

Take home messages

>50 yo R/o Cado castsCT (not u/s or ivp)