Now what? Evaluation of Hematuria

Evaluation of
Hematuria
Matthew Simmons, MD, PhD
Urology Specialists of Oregon
Bend, OR
There’s blood in the urine: Now what?
• How much blood warrants work-up?
• What could be the cause?
• What kind of evaluation is needed?
History of Urinalysis
• Urine was used to assess
health 6000 years ago
• In the Middle ages
“Uroscopy” matched
urine to a color chart to
make a diagnosis
Modern Urinalysis
• Quantitative and rapid analysis
• Detection of:
– Blood
– Ketones
– Specific gravity
– Glucose
– Leukocytes
– Bacteria
What your patient sees
• Hematuria
– Invisible = Microscopic hematuria
– Visible = Gross hematuria
Initial Test: Urine dipstick analysis
• Performed in uncentrifuged
specimen
• 95% sensitive
• 75% specific
• Abnormal results must be
confirmed with microscopic
evaluation
Gross Hematuria
• One episode is enough to warrant formal
urological evaluation
• Colors vary – be suspicious
• Amount of blood doesn’t correlate to severity
of problem
Questions to ask
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Painful or painless?
Timing of bleeding?
Dysuria?
After exercise?
After recent surgery or illness?
Smoker?
Period?
Microhematuria
• Conducted based on micro analysis of 10ml of
urine spun 10 minutes at 2000RPM
• Sediment is resuspended
• Urine evaluated at 400X magnification
Definition of Microhematuria
• >3 RBCs per high power field
present in 2 of 3 specimens
• If criteria are met then the
patient qualifies for a formal
urology evaluation
Teaching point
• Patients require a formal evaluation if they
have:
– Microhematuria = 3 RBCs per HPF in 2 studies
– Gross hematuria of any kind
Causes
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Medical
Infectious
Obstructive
Malignant
Treatment-related
What is a formal evaluation?
• Upper tract imaging
• Cystoscopy
• (Cytology)
• Purpose is to rule identify cause as benign or
pathologic
Imaging
• CT-Urogram > CT with & without IV contrast >
non-contrast CT
• MRI does not detect stones, is costly
• Renal US is sufficient but provides lower
reliability data
Concerns with imaging
• Cost
• Underlying kidney disease
• Radiation exposure (especially in minors or
women of reproductive age)
Cystoscopy
• Only way to accurately assess bladder for
stones, tumors or other abnormalities
• An office procedure
Urine cytology
• High cost
• Low sensitivity, high specificity
• Only indicated in specific cases
Teaching Point
• Formal evaluation for hematuria is:
– Upper tract imaging
– Cystoscopy
– Urine cytology used to be part of formal
evaluation but is now only done is specific cases
UTIs
• Uncomplicated – Urinary frequency, urgency,
dysuria
• Complicated – Fever, chills, flank pain
UTI Pathology
• Bactria grow in urine, adhere to epithelial cells
and trigger an immune response
• Associated with:
– Intercourse (Introduction of bacteria)
– Vulvar atrophy (Lessened immunity)
– Incomplete emptying (Inability to clear)
– Foreign bodies, stones (Nidus for infection)
Hematuria and UTIs
• Always send urine for culture
• Treat the UTI and repeat the UA 3-4 weeks
afterwards and in absence of lower tract
symptoms
• If they meet criteria for microhematuria or
have repeat gross hematuria then evaluation
is needed
Stones
• Common cause of microscopic and gross
hematuria
– Prior history of stones?
– Associated pain?
Stones
• Kidney, ureter or bladder
• Calcium oxalate, uric acid, struvite
• Concurrent UTI or renal failure?
BPH
• Common benign cause
of hematuria in older
men
• Due to turbulent flow
and friable blood
vessels
• A diagnosis of
exclusion
Incomplete emptying
• Can be due to kidney/ureter
obstruction (UPJO, stricture,
tumor)
• Can be due to lower tract
obstruction (BPH, diverticuli,
tumor)
• Obstruction can lead to UTI or
tumors
Tumors
• Most important diagnosis
to rule out
• Can be renal primary (RCC)
• Can be urothelial – Arise
from collecting system,
ureter and bladder
Renal tumors
• Renal cell carcinoma
• Arise from kidney tissues
• Diagnosis confirmed by
presence of contrast
enhancement
Urothelial Tumors
• Can be located in kidney, ureter or, most
commonly, bladder
• Cystoscopy assesses for papillary tumors or
CIS
Medical Renal Causes
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IgA Nephropathy
Thin Basement Membrane Disease
Benign Familial Microhematuria
Glomerulonephritis
Clues for Medical Renal Causes
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Elevated creatinine
Proteinuria or glucosuria
Negative formal evaluation
Specific microscopic findings
Cystitis
• Interstitial cystitis
– Dx of exclusion, Rare, Hallmark is pain with
urination in absence of infection
• Radiation cystitis
– Common in men 5-10 years after prostate RT
Anticoagulation
• Will not cause de novo hematuria
• Usually unmasks an underlying problem such
as tumor or stone
Imposters
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Myoglobin (myoglobinuria)
Porphyin (porphyria)
Betanin (from beets)
Rifampin, Pyridium medications
Summary
• Gross hematuria always warrants evaluation
• Microhematuria is >3RBCs/HPF on 2 studies
• Formal evaluation consists of upper tract
imaging and cystoscopy
• When in doubt, refer!