HematuriaHematuriaResident LectureResident Lecture

HematuriaHematuriaDiagnosis: presence of ≥ 3 RBCs

on at least 2 separate urine samples◦Gross: as little as 1cc can visibly

change urine◦Microscopic: detected by UA if there

is at least 1-2 RBC/hpf Because there are false positives urine

microscopy is necessary to confirm presence of RBCs

Evaluation of hematuriaEvaluation of hematuriaHistory taking is VERY important

◦Risk factors Smoking history Occupational exposure to chemicals or dyes (benzenes

or aromatic amines) History of gross hematuria Age >40 years History of urologic disorder or disease History of irritative voiding symptoms History of urinary tract infection Analgesic abuse History of pelvic irradiation

◦Systemic symptoms, exposures, exercise, infections, BPH, stones, dysuria, etc.

Evaluation of hematuriaEvaluation of hematuriaUrine microscopy confirms RBCs

present?Gross v. microscopic hematuria?Proteinuria present, how much?Glomerular v. nonglomerular?

◦Glomerular: RBC casts, dysmorphic RBCs, proteinuria (typically > 1 gm), coca-cola color

◦Nonglomerular: nondysmorphic RBCs, clot formation (very rare in glomerular bleeding)

◦ Indeterminate: presence of less than < 30 % dysmorphic RBCs, Proteinuria < 1gm, no RBC casts

Renal U/S results?

Etiology of Glomerular Etiology of Glomerular hematuriahematuriaGlomerulonephriti

sSystemic disease

(autoimmune)◦ Vasculitis – (WG,

MPA, CS, HSP)◦ Lupus◦ TMA◦ Scleroderma

Hereditary/Other◦ Alport’s◦ TBM◦ Infection-associated

GN◦ Nutcracker

syndrome◦ Loin-pain hematuria

Evaluation of nonglomerular Evaluation of nonglomerular hematuria - LUThematuria - LUT

Imaging studies for Imaging studies for nonglomerular hematurianonglomerular hematuria

OutcomeOutcome1% of older patients with an

initially negative evaluation will, at three to four years, have a detectable urinary tract malignancy

In high risk patients, f/u cytology at 6, 12, 24, 36 months, consider repeat cystoscopy annually for persistent hematuria