Hematuria

Background

• 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

1. Younger pt
   1. Infection
   2. Nephrolithiasis
2. Older pt
   1. Neoplasm
   2. BPH
3. Peds
   1. Glomerulonephritis
4. Any age
   1. Schistosomiasis (most common cause worldwide)

Causes of False Hematuria on Visual Inspection

1. Munchausen syndrome, malingering, drug seeking
   1. Patients may add blood to voided urine for secondary gain
2. Medications
   1. NSAIDs, phenytoin, phenothiazines, quinine, rifampin, sulfasalazine, others
3. Foods and dyes
   1. Beets, berries, rhubarb
4. Serratia marcescens infection
5. Amorphous urates
6. Hemoglobinuria, myoglobinuria, porphyrins

Clinical Features

Types of hematuria

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

DDx

1. Urologic (lower tract)
   1. Any location
      1. Iatrogenic/postprocedure
      2. Trauma
      3. Infection
      4. Stones/calculi
      5. Erosion or mechanical obstruction by tumor
   2. Ureter(s)
      1. Dilatation of stricture
   3. Bladder
      1. Transitional cell carcinoma
      2. Vascular lesions or malformations
      3. Chemical or radiation cystitis
   4. Prostate
      1. Benign prostatic hypertrophy
      2. Prostatitis
   5. Urethra
      1. Stricture
      2. Diverticulosis
      3. Foreign body
      4. Endometriosis (cyclic hematuria with menstrual pain)
2. Renal (upper tract)
   1. Glomerular
      1. Glomerulonephritis
      2. Immunoglobulin A nephropathy (Berger disease)
      3. Lupus nephritis
      4. Hereditary nephritis (Alport syndrome)
      5. Toxemia of pregnancy
      6. Serum sickness
      7. Erythema multiforme
   2. Nonglomerular
      1. Interstitial nephritis
      2. Pyelonephritis
      3. Papillary necrosis: sickle cell disease, diabetes, NSAID use
      4. Vascular: arteriovenous malformations, emboli, aortocaval fistula
      5. Malignancy
      6. Polycystic kidney disease
      7. Medullary sponge disease
      8. Tuberculosis
      9. Renal trauma
3. Hematologic
   1. Primary coagulopathy (e.g., hemophilia)
   2. Pharmacologic anticoagulation
   3. Sickle cell disease
4. Miscellaneous
   1. Eroding abdominal aortic aneurysm
   2. Malignant hypertension
   3. Loin pain–hematuria syndrome
   4. Renal vein thrombosis
   5. Exercise-induced hematuria
   6. Cantharidin (Spanish fly) poisoning
   7. Stings/bites by insects/reptiles having venom with anticoagulant properties