Hematuria: Difference between revisions
 
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''This page is for <u>adult</u> patients; for pediatric patients see [[hematuria (peds)]]''
''This page is for <u>adult</u> patients; for pediatric patients see [[hematuria (peds)]]''
==Background==
==Background==
*Make sure hematuria is not myoglobin or bleeding from non-urinary source
*Hematuria can be macroscopic/gross or microscopic
**Microscopic hematuria generally defined as >3 RBCs per high-power field of an uncontaminated sample
*Hematuria can also be divided into glomerular and nonglomerular causes
*Make sure hematuria is not myoglobin (due to rhabdo), hemoglobinuria (due to hemolysis), or bleeding from non-urinary source (ex. menstruation)
*Hematuria + pain suggests UTI or nephrolithiasis
*Hematuria + pain suggests UTI or nephrolithiasis
*Hematuria + no pain suggests malignancy, hyperplasia, or vascular cause
*Hematuria + no pain suggests malignancy, hyperplasia, or vascular cause
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==Clinical Features==
==Clinical Features==
[[File:HematuriaGross.jpg|thumb|Gross hematuria on urine sample.]]
[[File:The presence of blood in urine bag.jpg|thumb|Hematuria in a foley bag.]]
{{Types of hematuria}}
{{Types of hematuria}}


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==Evaluation==
==Evaluation==
[[File:Macroscopic hematuria.png|thumb|Macroscopic Hematuria algorithm]]
[[File:Macroscopic hematuria.png|thumb|Macroscopic Hematuria algorithm]]
===Workup===
===Workup===
*Labs:
====Labs====
**[[Urinalysis]]
*[[Urinalysis]]
***Microscopic hematuria associated with proteinuria suggests glomerular disease and requires further investigation (as an outpatient)
**Urine microscopy can show abnormal RBC morphologies suggesting glomerular source of hematuria
**CBC - for anemia and thrombocytopenia
**Microscopic hematuria associated with proteinuria suggests glomerular disease and requires further investigation (as an outpatient)
**BMP - for renal function
*Urine dipstick may be performed quickly in some centers but has high false-positive rate<ref>Saleem MO, Hamawy K. Hematuria. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534213/</ref>
*Consider CT imaging to assess for renal tumors, stones, or aneurysm
*CBC - for anemia and thrombocytopenia
*BMP - for renal function
*Coags
 
 
====Imaging====
*Utilize multiphasic CT urography ("hematuria protocol") to assess for pathology in the kidney and urinary collecting system<ref>Sharp VJ, Barnes KT, Erickson BA. Assessment of asymptomatic microscopic hematuria in adults. Am Fam Physician. 2013 Dec 1;88(11):747-54. PMID: 24364522.</ref>
**A noncontrast phase is useful for visualizing stones or hydronephrosis
**A nephrographic phase has contrast enhancing renal parenchyma, useful for pyelonephritis and renal tumors
**A delayed excretory phase visualizes urothelial and bladder tumors
*Ultrasound useful to assess for [[Renal ultrasound|hydronephrosis]] or a [[Aortic ultrasound|Abdominal Aortic Aneurysm]]
*Ultrasound useful to assess for [[Renal ultrasound|hydronephrosis]] or a [[Aortic ultrasound|Abdominal Aortic Aneurysm]]
*Ultimately, cystoscopy and/or kidney biopsies may be necessary as follow-up procedures after the final disposition


===Diagnosis===
===Diagnosis===
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**Hemodynamically stable without life-threatening cause of hematuria
**Hemodynamically stable without life-threatening cause of hematuria
**Able to tolerate oral fluids, antibiotics, and analgesics as indicated
**Able to tolerate oral fluids, antibiotics, and analgesics as indicated
**Able to void
**No significant anemia or acute renal insufficiency
**No significant anemia or acute renal insufficiency


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***[[Proteinuria]]
***[[Proteinuria]]
***Renal insufficiency
***Renal insufficiency
*Consider nephrology referral for signs of glomerular hematuria such as concommittant AKI, proteinuria, dysmorphic RBCs, RBC casts


===Admission===
===Admission===
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==References==
==References==
<references/>
<references/>
==Video==
{{#widget:YouTube|id=q4_O8kTArX4}}


[[Category:Renal]]
[[Category:Renal]]
[[Category:Urology]]
[[Category:Urology]]
[[Category:Symptoms]]
[[Category:Symptoms]]

Latest revision as of 20:11, 17 April 2024

This page is for adult patients; for pediatric patients see hematuria (peds)

Background

  • Hematuria can be macroscopic/gross or microscopic
    • Microscopic hematuria generally defined as >3 RBCs per high-power field of an uncontaminated sample
  • Hematuria can also be divided into glomerular and nonglomerular causes
  • Make sure hematuria is not myoglobin (due to rhabdo), hemoglobinuria (due to hemolysis), or bleeding from non-urinary source (ex. menstruation)
  • Hematuria + pain suggests UTI or nephrolithiasis
  • Hematuria + no pain suggests malignancy, hyperplasia, or vascular cause

Common Causes

Clinical Features

Gross hematuria on urine sample.
Hematuria in a foley bag.

Types of hematuria

  • Initial hematuria
    • Blood at beginning of micturition with subsequent clearing
    • Suggests urethral disease
  • Intervoid hematuria
    • Blood between voiding only (voided urine is clear)
    • Suggests lesions at distal urethra or meatus
  • Total hematuria
    • Blood visible throughout micturition
    • Suggests disease of kidneys, ureters, or bladder
  • Terminal hematuria
    • Blood seen at end of micturition after initial voiding of clear urine
    • Suggests disease at bladder neck or prostatic urethra
  • Gross hematuria
    • Indicates lower tract cause
  • Microscopic hematuria
    • Tends to occur with kidney disease
  • Brown urine with RBC casts and proteinuria
    • Suggests glomerular source
  • Clotted blood
    • Indicates source below kidneys

Blunt Trauma[1]

Renal injuries are associated with:

  • Sudden deceleration injury without hematuria
  • Gross Hematuria
  • Microscopic Hematuria with Shock (SBP<90 mm Hg)
  • The degree of hematuria does not correlate with significance of renal injury

Differential Diagnosis

Hematuria

Sources of hematuria.

Evaluation

Macroscopic Hematuria algorithm

Workup

Labs

  • Urinalysis
    • Urine microscopy can show abnormal RBC morphologies suggesting glomerular source of hematuria
    • Microscopic hematuria associated with proteinuria suggests glomerular disease and requires further investigation (as an outpatient)
  • Urine dipstick may be performed quickly in some centers but has high false-positive rate[2]
  • CBC - for anemia and thrombocytopenia
  • BMP - for renal function
  • Coags


Imaging

  • Utilize multiphasic CT urography ("hematuria protocol") to assess for pathology in the kidney and urinary collecting system[3]
    • A noncontrast phase is useful for visualizing stones or hydronephrosis
    • A nephrographic phase has contrast enhancing renal parenchyma, useful for pyelonephritis and renal tumors
    • A delayed excretory phase visualizes urothelial and bladder tumors
  • Ultrasound useful to assess for hydronephrosis or a Abdominal Aortic Aneurysm
  • Ultimately, cystoscopy and/or kidney biopsies may be necessary as follow-up procedures after the final disposition

Diagnosis

  • Based on UA
    • Isolated hematuria with dysmorphic red cells or red cells with a decreased mean corpuscular volume (MCV), should prompt an evaluation for glomerulopathy (e.g., IgA nephropathy & Alport's syndrome)[4]
    • Isolated hematuria may be elusive. In some series, more than half of the patients have microhematuria with no definable cause.[5]

Management

  • Treat underlying cause
  • Gross hematuria
    • Often associated with intravesicular clot formation and bladder outlet obstruction
      • Use triple-lumen urinary drainage catheter with intermittent or continuous bladder irrigation
        • Adequate urinary drainage must be ensured; otherwise consult urology

Disposition

Outpaient

  • Outpatient management appropriate if:
    • Hemodynamically stable without life-threatening cause of hematuria
    • Able to tolerate oral fluids, antibiotics, and analgesics as indicated
    • Able to void
    • No significant anemia or acute renal insufficiency

Referral Considerations

  • Patients <40 yr: refer to primary care provider for repeat UA within 2wk
  • Patients >40 yr with risk factor for urologic cancer: refer to urologist within 2wk
    • Risk factors:
      • Smoking history
      • Occupational exposure to chemicals or dyes
      • History of gross hematuria
      • Previous urologic history
      • History of recurrent UTI
      • Analgesic abuse
      • History of pelvic irradiation
      • Cyclophosphamide use
      • Pregnancy
      • Known malignancy
      • Sickle cell disease
      • Proteinuria
      • Renal insufficiency
  • Consider nephrology referral for signs of glomerular hematuria such as concommittant AKI, proteinuria, dysmorphic RBCs, RBC casts

Admission

If:

See Also

References

  1. ↑ Mee S. et al. Radiographic assessment of renal trauma: A 10-year prospective study of patient selection. J Urology. 1989 May;141(5):1095-8
  2. ↑ Saleem MO, Hamawy K. Hematuria. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534213/
  3. ↑ Sharp VJ, Barnes KT, Erickson BA. Assessment of asymptomatic microscopic hematuria in adults. Am Fam Physician. 2013 Dec 1;88(11):747-54. PMID: 24364522.
  4. ↑ Ingelfinger, J. (2021). Hematuria in Adults. The New England Journal of Medicine, 385(2), 153–161.
  5. ↑ Ingelfinger, J. (2021). Hematuria in Adults. The New England Journal of Medicine, 385(2), 153–161
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