Hematuria

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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

Clinical Features

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

Workup

  • Labs:
    • Urinalysis
        • Microscopic hematuria associated with 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[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

  • Urologic (lower tract)
    • Any location
    • Ureter(s)
      • Dilatation of stricture
    • Bladder
      • Transitional cell carcinoma
      • Vascular lesions or malformations
      • Chemical or radiation cystitis
    • Prostate
    • Urethra
      • Stricture
      • Diverticulosis
      • Foreign body
      • Endometriosis (cyclic hematuria with menstrual pain)
  • Renal (upper tract)
    • Glomerular
    • 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
  • Myoglobinuria - positive blood, no RBCs: rhabdomyolysis
  • Hemoglobinuria - positive blood, no RBCs
  • 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

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

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

See Also

Hematuria (Peds) DDx

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