Hematuria

Key Features

• Both gross and microscopic hematuria require evaluation

• The upper urinary tract should be imaged

• Cystoscopy should be performed if there is hematuria in the absence of an identifiable benign cause

• Urinary cytology can be obtained after initial negative imaging and cystoscopic evaluation

• If work-up is negative, the cystoscopy and upper tract imaging should be repeated after 1 year

Clinical Findings

• If gross hematuria occurs, a description of the timing (initial, terminal, total) may provide a clue to the localization of disease

• Associated symptoms to inquire about

  • Renal colic

  • Irritative voiding symptoms

  • Constitutional symptoms

• Signs of systemic disease

  • Fever

  • Rash

  • Lymphadenopathy

  • Abdominal or pelvic masses

• Signs of medical kidney disease

  • Hypertension

  • Volume overload

• Urologic evaluation may demonstrate

  • Enlarged prostate

  • Flank mass

  • Urethral disease

Diagnosis

• Urinalysis and urine culture

• Microhematuria is defined as 3 or more red blood cells per high power field on a microscopic evaluation of the urine

• A positive dipstick reading for heme merits microscopic examination to confirm or refute the diagnosis of hematuria but is not enough to warrant workup on its own

• If urinalysis and culture is suggestive of a urinary tract infection, follow-up urinalysis after treatment of the infection is important to ensure resolution of the hematuria

• An estimate of kidney function should be obtained since renal insufficiency may influence the methods of further evaluation (eg, ability obtain contrast imaging) and management of patients with hematuria

• Urine cytology and other urinary-based markers are not routinely recommended in the evaluation of asymptomatic microscopic hematuria

• CT-intravenous pyelogram (CT-IVP)

  • Upper tract should be imaged with no contrast, with contrast, and with excretory delayed imaging to identify neoplasms of the kidney or ureter as well as benign conditions such as

    • Urolithiasis

    • Obstructive uropathy

    • Papillary necrosis

    • Medullary sponge kidney

    • Polycystic kidney disease

• A magnetic resonance urogram without and with contrast can be performed for patients with relative or absolute contraindications that preclude a CT-IVP, such as

  • Kidney disease

  • Intravenous contrast allergy

  • Pregnancy

• Ultrasonographic evaluation of the urinary tract for hematuria

  • Role is unclear

  • Although it may provide adequate information about the kidney, its sensitivity in detecting ureteral disease is lower

• Cystoscopy

  • Is necessary for

    • Bladder or urethral neoplasm

    • Benign prostatic hyperplasia

    • Radiation or chemical cystitis

  • Indications

    • Gross hematuria

    • Presence of asymptomatic microscopic hematuria in patients > 35 years old

  • Best performed while patient is actively bleeding to allow better localization

Treatment

• Should be directed to the underlying cause of the hematuria