Hematuria

Background

Macroscopic Hematuria algorithm

• Make sure hematuria is not myoglobin or bleeding from non-urinary source
• Hematuria + pain suggests UTI
• Hematuria + no pain suggests malignancy, hyperplasia, or vascular cause

Common Causes

• Pediatric patients
  • Glomerulonephritis
  • UTI
  • Congenital urinary tract anomaly
• Younger adults
  • UTI
  • Nephrolithiasis
• Older adults
  • UTI
  • Neoplasm
  • BPH
• Any age
  • Schistosomiasis (most common cause worldwide)

Clinical Features

Types of hematuria

• Initial hematuria
  • Blood at beginning of micturition w/ subsequent clearing
  • Suggests urethral disease
• Intervoid hematuria
  • Blood between voiding only while 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 w/ RBC casts and proteinuria
  • Suggests glomerular source
• Clotted blood
  • Indicates source below kidneys

Workup

Labs

• UA
• Microscopic hematuria assoc w/ proteinuria requires further investigation (as an outpatient)
  • Suggests glomerular disease
• Consider CT imaging to assess for renal tumors, stones, or aneurysm
• Ultrasound useful to assess for hydronephrosis or a Abdominal Aortic Aneurysm

Blunt Trauma

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.

• Urologic (lower tract)
  • Any location
    • Iatrogenic/postprocedure
    • GU trauma
    • Infection
    • Kidney stone
    • Erosion or mechanical obstruction by tumor
  • Ureter(s)
    • Dilatation of stricture
  • Bladder
    • Transitional cell carcinoma
    • Vascular lesions or malformations
    • Chemical or radiation cystitis
  • Prostate
    • Benign prostatic hypertrophy
    • Prostatitis
  • Urethra
    • Stricture
    • Diverticulosis
    • Foreign body
    • Endometriosis (cyclic hematuria with menstrual pain)
• Renal (upper tract)
  • Glomerular
    • Glomerulonephritis
    • IgA nephropathy (Berger disease)
    • Lupus nephritis
    • Hereditary nephritis (Alport syndrome)
    • Toxemia of pregnancy
    • Serum sickness
    • Erythema multiforme
  • Nonglomerular
    • Interstitial nephritis
    • Pyelonephritis
    • Papillary necrosis: sickle cell disease, diabetes, NSAID use
    • Vascular: arteriovenous malformations, emboli, aortocaval fistula
    • Malignancy
    • Polycystic kidney disease
    • Medullary sponge disease
    • Tuberculosis
    • Renal trauma
• Hematologic
  • Primary coagulopathy (e.g., hemophilia)
  • Pharmacologic anticoagulation
  • Sickle cell disease
• Myoglobinuria - positive blood, no RBCs: rhabdomyolysis
• Hemoglobinuria - positive blood, no RBCs
  • TTP / HUS
  • DIC
  • Mechanical valve emergency
  • Hemolytic anemia
  • Paroxysmal Nocturnal Hemoglobinuria
• Miscellaneous
  • Eroding abdominal aortic aneurysm
  • Malignant hypertension
  • Loin pain–hematuria syndrome
  • Renal vein thrombosis
  • Exercise-induced hematuria
  • Cantharidin (Spanish fly) poisoning
  • Stings/bites by insects/reptiles having venom with anticoagulant properties
  • Schistosomiasis
  • Sickle Cell Trait

Pediatric Hematuria

Macroscopic Hematuria	Transient Microhematuria	Persistent Microhematuria
Blunt abdominal trauma	Strenuous exercise	Benign familial hematuria
Urinary tract infection	Congenital anomalies	Idiopathic hypercalciuria
Nephrolithiasis	Trauma	Immunoglobulin A nephropathy
Infections	Menstruation
Poststreptococcal glomerulonephritis	Bladder catheterization	Alport syndrome
	High fever	Sickle cell trait or anemia
Immunoglobulin A nephropathy		Henoch-Schonlein purpura
Hypercalciuria		Drugs and toxins
Sickle cell disease		Lupus nephritis

Look-Alikes

• Foods or medications
  • For example beets, rifampin, multivitamins, pyridium
• Uric acid crystalluria
• Gastrointestinal bleeding (peds)
• Vaginal bleeding
  • Prepubertal vaginal bleeding
• Other causes of abnormally colored urine

Management

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

Disposition

• Outpatient management appropriate if:
  • Hemodynamically stable without life-threatening cause of hematuria
  • Able to tolerate oral fluids, abx, and analgesics as indicated
  • No significant anemia or acute renal insufficiency
• Patients <40 yr: refer to primary care physician for repeat UA w/in 2wk
• Patients >40 yr w/ risk factor for urologic cancer: refer to urologist w/in 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
• Admit:
  • Intractable pain
  • Intolerance of oral fluids and medications
  • Bladder outlet obstruction
  • Suspected or newly diagnosed glomerulonephritis
    • High risk of developing complications (pulm edema, vol overload, HTN emergency)
  • Pregnant women (hematuria can accompany preeclampsia, pyelo or obstructing stone)

See Also

Hematuria (Peds) DDx