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Understand hematuria

 

HEMATURIA

 

Definition:  blood in the urine (macroscopic – grossly visible, microscopic – only visible with microscope)

 

Check urine dip:

+ blood, +RBCs suggests true hematuria

+blood, -RBCs suggests myoglobinuria (such as from rhabdomyolysis)

 

3 important questions:

1.  How old is the patient?

-patients older than 50 years have much increased risk of malignancy (bladder, renal, prostate)

-these patients should be evaluated with urine CYTOLOGY and imaging (CT or IVP)

 

2.  Are there any clues from the history or physical exam?

-concurrent pyuria and dysuria, consider UTI

-recent URI, consider post-infectious glomerulonephritis

-family history of renal disease, consider hereditary nephritis, polycystic kidney disease, sickle cell disease

-unilateral flank pain radiating to groin, consider ureteral obstruction (kidney stone, clot, cancer)

-hesitancy/dribbling, consider BPH

-history of bleeding disorders or bleeding from multiple sites, consider DIC

-cyclic in a woman, consider menses or endometriosis

-living in endemic area, consider Schistosomiasis haematobium

-sterile pyuria with hematuria, consider renal TB

-elevated creatinine consistent with renal failure

 

2.  Is the bleeding from glomerular or extraglomerular source?

-glomerular = RED BLOOD CELL CASTS on microscopy

-also see dysmorphic RBCs and protein >500mg/day

-glomerular causes include IgA nephropathy, Alport syndrome, thin BM disease, post-infectious glomerular nephritis

-extraglomerular = only RBC and clots

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