Hematuria

Key Features

Essentials of Diagnosis

• Gross hematuria requires evaluation

  • Upper urinary tract should be imaged

  • Lower urinary tract should be evaluated by cystoscopy

• In microscopic hematuria, the workup should be risk stratified

• General ConsiderationsAn upper tract source (kidneys and ureters) can be identified in 10% of patients with gross or microscopic hematuria

• A lower tract source of gross hematuria (in the absence of infection) most commonly caused by

  • Bleeding prostatic varices

  • Urothelial carcinoma of the bladder

• Microscopic hematuria in the male is most commonly due to

  • Benign prostatic hyperplasia (13%)

  • Kidney stones (6%)

  • Urethral stricture (1.4%)

• Presence of hematuria in patients receiving antiplatelet or anticoagulation therapy

  • Cannot be presumed to be due to the medication

  • Warrants complete evaluation, consisting of

    • Upper tract imaging

    • Cystoscopy

    • Urine cytology

Clinical Findings

History

• The history should obtain information regarding

  • Risk factors for urothelial cancer

    • Age

    • Male sex

    • Smoking

    • History of gross hematuria

    • Irritative lower urinary tract voiding symptoms

    • History of cyclophosphamide or ifosfamide chemotherapy

    • Family history of urothelial carcinoma or Lynch syndrome

    • Occupational exposure to benzene chemicals or aromatic amines

    • History of chronic indwelling foreign body in the urinary tract

  • Nonmalignant causes

Symptoms and Signs

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

• Associated symptoms

  • 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

Laboratory Findings

• Initial tests include a urinalysis and urine culture

• Microhematuria is defined as three 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 kidney disease may influence the methods of further evaluation and management (eg, ability to obtain contrast imaging) of hematuria

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

Imaging

• Patients with gross hematuria should have both complete evaluation of the upper tract by a CT-intravenous pyelogram (CT-IVP) or a magnetic resonance urogram (MR-urogram) with and without contrast

Evaluation

• The American Urological Association classifies microhematuria as low-, medium-, and high risk for a urothelial malignancy

  • Low-risk ...