Qiuyang Li, PGY2 Emory Family M edicine. Hematuria. Gross hematuria: Suspected if a red or brown color change of urine Intermittent red or brown color urine a/w variety of clinical setting Medications (phenazopyridine, microbid, NSAID) Ingestion of beets or certain dyes
Suspected if a red or brown color change of urine
Intermittent red or brown color urine a/w variety of clinical setting
Medications (phenazopyridine, microbid, NSAID)
Ingestion of beets or certain dyes
Myoglobinuria or hemoglobinuria
If pass clot, indicate lower urinary source
Centrifuge the specimen,
Supernatant be tested for heme (hemoglobin or myoglobin) with a urine dipstick.
The urine sediment is the gold standard for the detection of microscopic hematuria
A positive dipstick test must always be confirmed with microscopic examination of the urine
Schematic representation of the major causes of hematuria in relation to the age at which they usually occur (horizontal axis), transience or persistence (vertical axis), and frequency (blue implies more frequent).
a three-tube test may also help to locate the source of bleeding in selected cases.
Urethral: First 10-15 mL
Bladder: Final 10-30 mL
Upper urinary tract: Throughout
History and Physical bleeding in selected cases.
Family history bleeding in selected cases.
Dialysis or transplant,
Sickle cell trait *:
Medication Hx bleeding in selected cases.
1. Concurrent pyuria and dysuria, indicate UTI, may also occur with bladder malignancy.
2. A recent URI, raise the possibility of either post infectious glomerulonephritis or IgA nephropathy
3. A positive family history of renal disease give suspicion of hereditary nephritis, polycystic kidney disease, or sickle cell disease.
4. Unilateral flank pain radiating to the groin, suggesting ureteral obstruction due to a calculus or blood clot, but can occasionally be seen with malignancy. Flank pain that is persistent or recurrent can also occur in the rare loin pain hematuria syndrome.
5. Symptoms of prostatic obstruction in older men such as hesitancy and dribbling. The cellular proliferation in BPH is associated with increased vascularity, and the new vessels can be fragile.
6. Recent vigorous exercise or trauma
7. History of a bleeding disorder or bleeding from multiple sites due to uncontrolled anticoagulant therapy.
8. Cyclic hematuria in women that is most prominent during and shortly after menstruation, suggesting endometriosis of the urinary tract .
9. Medications that might cause nephritis (usually with other findings, typically with renal insufficiency).
10. AA should be screened for sickle cell trait or disease, which can lead to papillary necrosis and hematuria.
11. Travel or residence in areas endemic for Schistosoma hematobium .
12.Sterile pyuria with hematuria, which may occur with renal tuberculosis, analgesic nephropathy and other interstitial diseases.
Glomerular or Extra Glomerular bleeding? diagnosis
Microscopic hematuria DDx diagnosis
Microscopic hematuria DDx diagnosis
Rare cause of Microscopic Hematuria diagnosis
Arteriovenous malformations and fistulas
Loin pain-hematuria syndrome
Arteriovenous malformations and fistulas diagnosis — An AV malformation (AVM) or fistula of the urologic tract may be either congenital or acquired. The primary presenting sign is gross hematuria, but high-output heart failure and hypertension also may be seen . The latter is presumably due to activation of the renin-angiotensin system resulting from ischemia distal to the AVM
Nutcracker syndrome — The nutcracker syndrome refers to compression of the left renal vein between the aorta and proximal superior mesenteric artery. Nutcracker syndrome can cause both microscopic and gross hematuria, primarily in children (but also adults) in Asia . The hematuria is usually asymptomatic but may be associated with left flank pain. Nutcracker syndrome has also been associated with orthostatic proteinuria.
Loin pain-hematuria syndrome — The loin pain-hematuria syndrome is a poorly defined disorder characterized by loin or flank pain that is often severe and unrelenting, and hematuria with dysmorphic red cell features suggesting a glomerular origin. Affected patients usually have normal kidney function.
Extraglomerular vs Glomerular in UA diagnosis
Findings on Microscopy diagnosis
Erythrocytes of uniform character are classified as isomorphic and suggest hematuria of lower urinary tract origin.
Microscopic clots of clumped erythrocytes in urine are also suggestive of lower urinary tract bleeding.
FIGURE 1. Typical morphology of erythrocytes from a urine specimen revealing microscopic hematuria. (phase contrast microscopy, 3100)
Urine sediment showing many red cells and an occasional larger white cell with a granular cytoplasm (arrows). The red cells have a uniform size and shape, suggesting that they are of nonglomerular origin
Dysmorphic erythrocytes are characterized by an irregular outer cell membrane and suggest hematuria of glomerular origin.
Red blood cell casts are also associated with a glomerular cause of hematuria.
FIGURE 2. Dysmorphic erythrocytes from a urine specimen. These cells suggest a glomerular cause of microscopic hematuria. (phase contrast microscopy, 3 100)
Transient or persistent hematuria outer cell membrane and suggest hematuria of glomerular origin.
Transient hematuria outer cell membrane and suggest hematuria of glomerular origin.
Transient microscopic hematuria is a common problem in adults
Fever, infection, trauma, and exercise are potential causes
It is reasonable to repeat an abnormal urinalysis in a few days
Malignancy risk in older patients with transient hematuria
In older patients, even transient hematuria carries an appreciable risk of malignancy (assuming no evidence of glomerular bleeding)
The risks includes : age >50, smoker and Hx of analgesic abuse.
Persistent hematuria manifestation of glomerular disease, one of three disorders is most likely
Underlying malignancy is greater in patients with persistent hematuria in whom there is no obvious cause from the history
The primary underlying cancers are bladder, renal, and, much less often, prostate
Laboratory Tests (initial work up) manifestation of glomerular disease, one of three disorders is most likely
Further urologic evaluation is warranted if more than three RBC/phf are found on at least two of three properly collected urine specimens or if high-grade microscopic hematuria (more than 100 red blood cells per high-power field) is found on a single urinalysis.17
Renal Biopsy manifestation of glomerular disease, one of three disorders is most likely
A biopsy is not usually performed for isolated glomerular hematuria (i.e., no proteinuria or renal insufficiency,) since there is no specific therapy for these conditions, unless the patient is considering becoming a kidney donor
However, biopsy should be considered if there is evidence of progressive disease as manifested by an elevation in the plasma creatinine concentration, increasing protein excretion, or an otherwise unexplained rise in blood pressure, even when the values remain within the normal range
Further Work up manifestation of glomerular disease, one of three disorders is most likely
Follow up manifestation of glomerular disease, one of three disorders is most likely
The combination of negative radiologic examination(s)
( IVP, US, CT scan, cytology, and cystoscopy) is usually sufficient to exclude malignancy in the urinary tract
However, approximately 1% of older pt with an initially negative evaluation will, at 3 to 4 years, have a detectable urinary tract malignancy
Initial and then periodic urine cytology and UA should be performed in pt at high risk for malignancy (at 6, 12, 24 and 36 months)
SCREENING FOR HEMATURIA manifestation of glomerular disease, one of three disorders is most likely
Thank you manifestation of glomerular disease, one of three disorders is most likely