Approach to Hematuria
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Transcript of Approach to Hematuria
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)