Hematuria

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

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

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

Should be directed to the underlying cause of the hematuria