hematuria qa

8/13/2019 Hematuria Qa

1/41

Approach to thePatient with

HematuriaPaul D. Simmons, MD

St. Marys Family Medicine ResidencyGrand Junction


2/41

No Financial Conflicts of Interest toDisclose

No Off-Label Uses of Medications Will BeDiscussed

Soundtrack Available on Glomerulus Records


3/41

Objectives

Define and classify hematuria.

Review the pathophysiology ofhematuria.

Discuss a rational diagnostic approachto the patient with hematuria.

Discuss effective use of lab andimaging tests in the hematuria work-up.


4/41

The ProblemA 40 year old woman

presents for a yearly health-maintenance examination.She is not currently on hermenstrual period. On herdipstick urinalysis, she has

2+ blood, trace protein,

trace leukocyte esteraseand negative nitrates.


5/41

Hematuria is defined as 2 of 3samples with:

1. Any number of RBCsper hpf.

2. More than 3 RBCs perhpf.

3. More than 30 RBCs perhpf.

4. 3+ blood on urinedipstick.

5. Visibly red urine.


6/41

Definitions

Hematuria is defined as threeor more RBCs per high-

powered fieldon urinemicroscopy, from 2 of 3

specimens.

In this photo, arrows point to WBCs surrounded bymonomorphic RBCs.


7/41

Unnecessary

Referrals Journal of Urolog y, February 2010: Retrospectiveanalysis of 320 new patient visits to a urology officewith the diagnosis non-macroscopic hematuria.

Of these referrals, only 41% had had microscopicurinalysis prior to referral, and only 24% had 3 ormore RBCs/hpf.

The Medicare cost of working up these 69 patientswithout microscopic confirmation was approx.

$45,000. Thirty-five of the 69 underwent cystoscopy;only one (with true hematuria) had a malignancy.

Moral of the story: Confirm hematuria withmicroscopy!


8/41

Take-Home Point #1:

Positive dipsticks for bloodshould get microscopic

confirmation.


9/41

Not All Red Urine is

Hematuria If the urine is visibly red, tea- orcola-colored, but there are < 3RBCs/hpf, consider:

Hemoglobinuria (false +dipstick)

Myoglobinuria (false + dipstick)

Beeturia

Rhubarburia

Medications (phenazopyridine,methyldopa, senna, others)

Porphyria


10/41


11/41

So, back to our 40

year old woman...

After her urine dipstick had 2+ blood,her urine was spun and the sedimentexamined microscopically, showing 10-

15 RBCs per hpf.


12/41

What would your next step be inevaluating this patient?

1. History and physicalexamination.

2. 24 hour urine

collection for creatinineclearance, K, Na,protein and UPEP.

3. Renal ultrasound andreferral for cystoscopy.

4. Repeat urine dipstickand micro in one year.


13/41

Age is probably the most important factor. ALMOST ALL intermittent hematuria is benign inpersons


14/41

Age and HematuriaAge (yr) Common Uncommon

0 to 15

Glomerulopathy (IgA, Alportssyndrome, thin BM disease,

APSGN)Hypercalciuria with stones

Congenital obstructive anomaliesUTIs

Sickle cell diseaseViral infection

FactitiousFeverHUS

HemophiliaHSP

Schistosomiasis

15-50

CalculiMenstrual contamination

ExerciseUTIsPKD

Sickle cell disease

IntercoursePapillary necrosis

AVMs or fistulaeDIC

Goodpastures syndromeLoin pain-hematuria syndrome

Renal infarctionRenal vein thrombosis

SchistosomiasisMedullary sponge kidney

>50

BPHCancer (renal, ureteral, bladder,

prostate)Overanticoagulation

PKD

Prostatitis

AVMs or fistulaeCyclic hematuria in women

EndometriosisTTP

Renal vein thrombosisToxins (cantharidin, djenkol

bean)LP-HS


15/41

History (cont.) Recent exercise or trauma? Recent travel? (Especially to Africa, Middle East

or India.)

PMH: coagulopathies (acquired or hereditary),irradiation, chemo.

Family Hx: hereditary nephritis, PKD, sickle celldisease.

Social Hx: smoking, industrial exposures(tetraethylchloride, benzene, aromatic amines)


16/41

RED FLAGS

Smoking history Occupational exposure to chemicals or dyes (benzenes or

aromatic amines)

History of gross hematuria Age >40 years (>50, some sources say) History of urologic disorder or disease (not simple UTIs) History of persistent irritative voiding symptoms History of recurrent or chronic urinary tract infection Analgesic abuse History of pelvic irradiation

Source: Urology 2001;57(4)


17/41

Physical Examination Vitals

fever? (pyelo) HTN? (glomerulonephritis)

Heart new murmur? (endocarditis)

Lungs crackles, rhonchi? (Goodpastures syndrome) Abdomen

masses? (cancer, obstruction) bruits? (renalischemia)

Extremities edema? (glomerulonephritis) rashes? (HSP,

CTD, SLE)

Rectal BPH? nodules? (cancer) tenderness?

(prostatitis, endometriosis)

Osler at the Bedside: Inspection,Auscultation, Palpation/Percussion and

Thought.


18/41


19/41

Welcome to...

YOU MAKE THEDIAGNOSIS!(Sponsored by Illness Scripts)


20/41

A 7 year old boy presents 2 weeks after anepisode of pharyngitis because his mother

noticed his urine was red. He has mild edemaon examination.

1. Schistosomiasis

2. Goodpasturessyndrome

3. Post-streptococcalglomerulonephritis

4. Prostatitis


21/41

A 50 year old man presents with 1 week of vaguepelvic discomfort, urinary hesitancy, frequency andnocturia. His examination reveals a temperature of

38.1 C and a tender, boggy prostate. His urinalysisshows 20-30 RBCs/hpf without pyuria or crystals.

1. Urolithiasis2. Pyelonephritis

3. Hemolytic-uremicsyndrome

4. Acute prostatitis


22/41

A 38 year old woman with chronic pelvic painpresents with macroscopic hematuria. She has

no fever, dysuria or flank pain. She notes thather urine only turns dark red with or soon afterher menstrual cycle.

1. Endometriosis

2. Exercise-inducedhematuria

3. Polycystic kidney disease4. Polycystic ovarian disease

5. Both B and C


23/41

A 28 year old man presents to the ER with thesudden onset of unilateral, severe flank pain

radiating to the ipsilateral groin. He is afebrile,but diaphoretic and nauseous. His urine dipstick

shows 3+ blood and trace leukocytes.

1. Drug-seeker

2. Urolithiasis

3. Ectopic pregnancy

4. Schistosomiasis


24/41

An 82 year old man presents to the ER with thesudden onset of unilateral, severe flank pain

radiating to the ipsilateral groin. He is afebrile,but diaphoretic and nauseous. His urine dipstickshows 3+ blood and trace leukocytes.

1. Drug-seeker2. Urolithiasis

3. Dissecting AAA

4. Post-streptococcal GN

5. Probably B, but I want torule out C


25/41

Take-Home Point #3:Look for typical clusters of

symptoms and signs to quicklyand roughly differentiate

between infection, stones andcancer.


26/41

But what if I donthave an easy slam-

dunk diagnosis?

What next?


27/41

Back to the

Microscope! Is it glomerular or non-glomerular?

Glomerular:acanthocytosis (acantho-, thorn or spike) or

casts.

Non-glomerular:isomorphic RBCs.


28/41

Glomerular - Casts andDysmorphic RBCs (arrow)


29/41

Glomerular -

Acanthocytes


30/41

Non-Glomerular - IsomorphicRBCs


31/41

Trick Slide - Crenated RBCs(arrowhead) in concentrated urine


32/41

Wevecome this

far.

New Engl J

Med 348;23

6/5/03


33/41

If its glomerular...

Again: acanthocytes or casts in thesediment...

If noprotein or renal failure, youredone for now.

But follow-up regularly! If protein or renal failure, refer to

nephrology! (Renal biopsy likely.)


34/41

If its non-

glomerular... Again, regular-appearing, isomorphic RBCs. Ask: where, then, is the bleeding from? Step 1: CT urogram. Looks for the big anatomical lesions.

If no lesion, then-- Step 2: Urine cytology(3 first AM samples)

if abnormal, go to cystoscopy.

Step 3: Is the patient high-risk for malignancy--over 40,toxic exposures, irradiation, etc.? if yes, go to cystoscopy anyway and consider

repeating cytology at 6, 12, 24 and 36 months.


35/41

CT Urography Journal of Urology , March 2008: Retrospective review of

the radiologic, pathologic and urologic records of 468patients without prior hx of GU cancer.

All underwent CT urogram. 50 urinary system neoplasms diagnosed, with CT-U finding

32/50. Sensitivity = 64%, specificity = 98%, PPV = 76%,NPV = 96%.

Conclusion: CT-U is moderately sensitive and highlyspecific for GU neoplasm, but does not replace cystoscopyand urine cytology in high-risk patients with hematuria.

In other words: very helpful if abnormal, not very reassuringif normal.


36/41

Take-Home Point #4:a. Glomerular or Not?

b. Glomerular- refer if protein orrenal failure.

c. Not- do a CT-U, then cytology

(if needed), then see how worriedyou still are.


37/41

A 55 year old male smoker with isolatedmicroscopic hematuria (no fever, pyuria or

prostate symptoms) has isomorphic RBCs,no casts or acanthocytes on urine micro.What test would you order first?

1. Cystoscopy

2. Bilateral renal ultrasound

3. Intravenous pyelogram (IVP)

4. CT urogram


38/41

If the test you ordered in the lastquestion failed to show a lesion, which

referral would be most appropriate?

1. nephrology

2. psychiatry

3. urology

4. dermatology

5. chiropractic


39/41

Positive dipsticks for blood should get microscopic

confirmation R/O myo- or hemoglobinuria and decide glomerular vs.

non-glomerular.

Top 3 Suspects are: Infection, Stones and Malignancy.

Look for Illness Scripts ex: unilateral flank pain, afebrile, N/V (stones) ex: hematuria correlated with menses (endometriosis) ex: obstructive sxs, fever, prostate tenderness

(prostatitis)

ex: CVAT, fever, dysuria (pyelo) If its not easy, ask: Glomerular or Not?

Glomerular - protein or renal dz? If so, refer tonephrology.

Not - 1. CT-U 2. C tolo 3. C stosco .

What Have We Learned?


40/41

References Beers MH, et al., Merck Manual of Diagnosis and Therapy(18th print and online

editions), Chapter 226: Approach to the Genitourinary Patient: Isolated Hematuria. Cohen RA and Brown RS, Microscopic Hematuria, New England Journal of Medicine,

348:23, 5 June 2003.

Grossfeld GD, et al., Evaluation of asymptomatic microscopic hematuria in adults: theAmerican Urological Association best practice policy recommendations. Part II: patientevaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation, andfollow-up, Urology 2001; 57(4).

Kaplan M, et al., Essential Evidence Plus Online (www.essentialevidence.com),Hematuria, updated 9-11-2009, and Rauta V, EBM Guideline: Haemat-uria (6-3-2003).

Rao PK, et al., Dipstick Pseudohematuria: Unnecessary Consultation and Evaluation,J Urol, 2010 February; 183(2).

Rose BD, et al., UpToDate Online(www.uptodate.com), v. 17.3, Evaluation ofHematuria in Adults.

Sudakoff GS, et al., Multidetector CT Urography as the Primary Imaging Modality forDetecting Urinary Tract Neoplasms in Patients with Asymptomatic Hematuria,J Urol,2008 March, 179(3).

Zepf B, Evaluation of Patients with Microscopic Hematuria,American Family Physician,1 March 2004.

Schrute D, Beets and Urine Pennsylvania Beet Farms, vol 3, no. 6.
http://www.essentialevidence.com/http://www.uptodate.com/http://www.uptodate.com/http://www.essentialevidence.com/


41/41

Thank You!

hematuria qa

Documents