Hematuria differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Steven C. Campbell, M.D., Ph.D.;Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2], Omer Kamal, M.D.[3], Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [4]

Overview

Gross hematuria(GH) must be distinguished from pigmenturia, which may be due to endogenous sources (e.g., bilirubin, myoglobin,and porphyrins), foods ingested (e.g., beets and rhubarb), drugs (e.g., phenazopyridine), and simple dehydration. This distinction can be made easily by urinalysis with microscopy. Notably, myoglobinuria and other factors can cause false-positive chemical tests for hemoglobin, so urine microscopy is required to confirm the diagnosis of hematuria. GH also must be distinguished from vaginal bleeding in women, which usually can be achieved by obtaining a careful menstrual history, collecting the specimen when the patient is not having menstrual or gynecologic bleeding, or, if necessary, obtaining a catheterized specimen. GH may also be detected by the presence of blood spotting on the undergarments of incontinent patients. After ruling out vaginal bleeding and mimics of hematuria, a urologic source must be suspected.

Differential Diagnosis

Hematuria should be differentiated from other disease which mimic hematuria especially hemoglobinuria and myoglobinuria which are dipstick positive but negative for microscopy.

Hematuria differential diagnosis

Differentiating the diseases that can cause hematuria:

Diseases Clinical manifestations Para-clinical findings Gold standard
Symptoms Physical examina
Lab Findings Diagnosi
Low back pain Fever Nausea/

Vomiting

Urinary symptoms Hypertension Pitting edema Other
Dysuria Frequency Oliguria
Glomerular diseases IgA nephropathy[1][2] (Berger nephropathy) + - - - + + + - - Biopsy:

IgA deposited in a diffuse granular pattern in the mesangium

Biopsy
Hereditary nephritis[3][4] (Alport syndrome) - - - - - - + -
  • Cataract
  • Hearing loss
Biopsy: Genetic analysis
Post-streptococcal glomerulonephritis[5][6] +/- + - - + + + +

Biopsy

Biopsy
Focal segmental glomerular sclerosis[7][8][9] - - - - - - + + Biopsy
  • Segmental solidification in the perihilar region and peripheral areas, especially the tubular pole
  • Coarsely granular deposits -of IgM and C3
Biopsy
Rapidly progressive glomerulonephritis[10][11][12] + + + - - - + - Biopsy: Biopsy
Lupus nephritis[13][14] - + - - - - + +
  • Foamy dark urine
  • Weight gain
Biopsy,
  • Different pathologies, CLICK HERE for more information.
Biopsy
Fabry disease - - - - - - + + - Biopsy Biopsy
Disease Low back pain Fever Nausea/

Vomiting

Dysuria Frequency Oliguria Hypertension Pitting edema Other Lab Findings Diagnosis method Gold standard
Tubulointerstitial diseases[15][16][17] + + + Rash Biopsy: Renal biopsy
Nephrolithiasis[18][19] + ± + ± ± ±
  • Radiating pain to groin
Abdominal CT scan without contrast
Reflux nephropathy (hydronephrosis) + + - - - - - +
Malignancy Renal cell carcinoma (RCC)[20][21] - - - - - - ± ±
Nephroblastoma (Wilms tumor)[22][23] - - - - - - - -

Biopsy:

Biopsy
Bladder cancer[27][28][29] - - - - ± ± - - Suprapubic pain Ultrasound, CT scan, Biopsy Biopsy
Prostate cancer[30][31] ± - - - ± ± - - - Ultrasound, CT scan, Biopsy Biopsy
Disease Low back pain Fever Nausea/

Vomiting

Dysuria Frequency Oliguria Hypertension Pitting edema Other Lab Findings Diagnosis method Gold standard
Familial diseases Polycystic kidney disease[32][33] + - - - - - + + Ultrasound:
  • Unilateral or bilateral cysts

CT:

  • Hyperdense appearance,
  • Septations
  • Calcifications

Genetic testing demonstrates:

  • Frame insertions/deletions
  • Non-canonical splice site alterations
  • Combined missense changes

Biopsy:

  • Interstitial fibrosis
  • Tubular atrophy
  • Thickening and lamellation of tubular basement membranes
Ultrasound
Vascular diseases Renal vein thrombosis[34][35] + + + - - - - - Renal venography: Gold standard
Wegner's granulomatosis polyangiitis[36][37][38][39] - - - - - +/- + + CT chest:

Biopsy:

Biopsy
Henoch-Schönlein purpura[40][41] - - - - - +/- +/- + Biopsy:

IgA deposited in a diffuse granular pattern in the mesangium

Renal biopsy, and clinical syndrome
Disease Low back pain Fever Nausea/

Vomiting

Dysuria Frequency Oliguria Hypertension Pitting edema Other Lab Findings Diagnosis method Gold standard
Lower urinary tract diseases Benign prostatic hyperplasia +/- - - + + - - -
  • Nocturia
  • Other voiding symptoms
    • Slow urinary stream
    • Splitting or spraying of the urinary stream
    • Intermittent urinary stream
    • Hesitancy
    • Straining to void
    • Terminal dribbling
  • Urinalysis to rule out UTI
  • Elevated BUN/Cr
  • High PSA values
  • Urine cytology to screen for bladder cancer
  • Biopsy to rule out cancer
Biopsy
Urolithiasis[42][43][44] + +/- + + + + - - Abdominppelvic CT scan without contrast Abdominppelvic CT scan without contrast
Disease Low back pain Fever Nausea/

Vomiting

Dysuria Frequency Oliguria Hypertension Pitting edema Other Lab Findings Diagnosis method Gold standard
Infectious diseases Pyelonephritis[45][46] + + + + + + - - CT and ultrasound: -
Cystitis[47][48] - - - + + + - - Ultrasound:
  • Presence of gas in the bladder wall.
  • Also, help to detect the presence of a tumor or a stone.
Urine culture
Prostatitis[49][50] - + - + + + - -
  • Body aches
Ultrasound:
  • Focal hypoechoic region located in the peripheral part of the prostate

CT scan:

-
Urethritis[51][52] -/- + - + + + - -

CT scan:

  • Diffuse, circumferential urothelial wall thickening and contrast-enhancement
  • Periureteric or perinephric fat stranding.
Urine culture
Urogenital trauma Inserted bladder or ureteral catheters - - - + + + - -
  • Retrograde urethrogram (RUG)
  • Retrograde urethrogram (RUG)

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