It’s a Bloody Mess!Hematuria

Wanda C. Hancock, MHSA, PA-C

ObjectivesDiscover the presenting symptoms for

hematuria and the anticipated decision path for its etiology

Develop an initial differential diagnosis for hematuria

Consider the diagnostic orders for developing the diagnosis

Determine the likely follow up testing.

Hematuria is a sign of malignancy until proven otherwise

Incidence43% of microscopic hematuria has no

etiology5% of microscopic hematuria is cancer23% of gross has cancer as an initial finding8% has no etiology initially but 18% findings

later

CausesCancerBPH TraumaSurgery/

instrumentationMedicationsRenal DiseaseExercise

StonesRadiationChemotherapyFeverBenzenesUTIRecent URTI

Risk FactorsAgeSmokingTraumaPrevious exposure to chemicals

How to Shine….Gross or microscopic?Timing?Pain?Clots?

Gross VS MicroGross hematuria

Always needs evaluationSources

MicroscopicDip stick has 90% sensitivity3-5 RBC HPF2 of 3 tests positive

Timing ….Initiation of the streamTerminal hematuria Throughout the micturation

Painful versus painlessPainful

CystitisStones

PainlessNeoplasm

Clots?AmorphousVeriform

PeePee on T(4)hisPeriod, pseudo hematuriaProstateObstructionNephritisTraumaTumorTBThrombosisHematologicInfection/InflammationStone

EvaluationPMHFMHPELaboratoryImaging

Past Medical HistoryRadiationSurgeryTBAutoimmune diseaseExerciseTraumaRecent URTILUTS

Family HistoryHTNPCKDAlport SyndromeStonesCancer

Physical ExaminationBlood pressurePallorRashesEdemaMurmurPalpable massFlank painDREPelvic

Laboratory testsUrine DipMicroscopic

examinationCultureCytologyCreatinine, BUNPT/INR

UrovisionOther

ANASCDTB

ImagingIVP or CT urogramUltrasoundMRI or CTRetrograde pyelogramMag 3 / renal scanCystogram

Differential DiagnosisPseudohematuria

Drugs, vegatables, dyesMyoglobinMenstrationDysfunctional bleeding

CongenitalCystic renal diseaseAlports diseaseRenal tubual disorder

Differential DiagnosisAnatomic

StricturesPhimosisPosterior urethral valvesDiverticulumUPJ obstructionVesicouretric reflux

Vascular malformationTraumaExercise inducedForeign body/inflammatory

Follow UpNegative CT, cytology, cystoscopyClinic follow up should be scheduled

6, 12, 24, 36 monthsUA, BP, cytology

RetestingChange of symptomsGross hematuria develops

ResourcesCampbell-Walsh Urology, 9th edition. Wein, Alan, et al.

Saunders/Elsevier, Philadelphia, PA, 2007.Clinical Manual of Urology, 3rd edition. Hanno, Phillip,

Malkowicz, S. Bruce, Wein, Alan. McGraw-Hill, NY, NY, 2007.Office Urology: The Clinican’s Guide. Kursh, Elroy D.,

Ulchaker, James C.. Humana Press, Totowa, NJ, 2001.Pocket Guide to Urology, 3rd edition. Wieder, Jeff A.. Griffith

Publishing, Caldwell, ID, 2007.Smith’s General Urology, 17th edition.Tanngho, Emil A.,

McAninch, Jack W.. McGraw-Hill/Lange, NY, NY, 2008.The 5-Minute Urologic Consult, 2nd edition. Gomella, Leonard G.

Lippincott Williams & Wilkins, Philadelphia, PA, 2010.Urology House Officer Series, 4th edition. Macfarlane, Michael T.

Lippincott Williams & Wilkins, Philadelphia, PA, 2006.