Hematuria overview
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Steven C. Campbell, M.D., Ph.D. Associate Editor(s)-in-Chief: Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [1]
Overview
Hematuria is the presence of blood in the urine and is a common condition in urological practice. It accounts for around 20% of urological referrals and is important, as it can be a cardinal symptom of urological malignancy. Around 40% of patients investigated for hematuria are found to have significant underling pathology, half of whom will have a urological malignancy. Therefore, all patients presenting with a single episode of haematuria require urgent investigation. Haematuria in adults should be regarded as a symptom of urological malignancy until proven otherwise. Microscopic hematuria, or microhematuria (MH), is defined as the presence of red blood cells (RBCs) on microscopic examination of the urine not evident on visual inspection of the urine. The prevalence of MH among healthy participants in screening studies is 6.5% (95% confidence interval [CI] 3.4 to 12.2), with higher rates in studies with a predominance of males, older patients, and smokers.
Definition
Definitions for MH vary considerably and range between 1 to 10 red blood cells per high-power fiel. [1] This difference is due to factors affecting related to sample collection and quantification. One of the the most widely used definition of MH is the presence of three or greater red blood cells per high power-field on a properly collected urinary specimen in the absence of an obvious benign cause (e.g. mild trauma or sexual activity preceding the collection).[2]
Classification
Hematuria may be classified based on its source, visibility, duration and pathophysiology.
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Causes
Causes of hematuria can range from benign conditions such as urinary tract infection to serious conditions such as bladder cancer.[3] Extrarenal site is responsible for more than 60% of cases of hematuria. Of these, the most important underlying disease is malignancy. In the primary care population, about 5% of patients with microscopic hematuria will have a urinary tract malignancy, mainly of the bladder or prostate. The most common nonmalignant causes of extrarenal hematuria are infections, such as cystitis, prostatitis, and urethritis.Regarding renal causes of microscopic hematuria, the most common cause of isolated glomerular hematuria (without significant proteinuria) is IgA nephropathy, followed by thin basement membrane disease, hereditary nephritis (Alport syndrome), and mild focal glomerulonephritis of other causes.[4]
Differential Diagnosis
Gross hematuria(GH) must be distinguished from pigmenturia, which may be due to endogenous sources (e.g., bilirubin, myoglobin, 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.
Epidemiology and Demographics
Asymptomatic hematuria is common in clinical practice, with a prevalence ranging from 0.18% to 38.7%.[5] Transient microscopic hematuria may occur in 6% to 39% of the population studied, but persistent microscopic hematuria in 3 or more consecutive urinalyses occurs less often, and is seen in 0.5% to 2% of the population under study. In the prevalence of underlying urinary tract disease, there is no clear difference between patients with transient microscopic hematuria and those with persistent microscopic hematuria.[6]
Risk Factors
Common risk factors for urinary tract malignancy in patients with hematuria:[7]
- Age older than 35 years
- Analgesic abuse
- Exposure to chemicals or dyes (benzenes or aromatic amines)
- Male sex
- Past or current smoking
- History of any of the following:
- Chronic indwelling foreign body
- Chronic urinary tract infection
- Exposure to known carcinogenic agents or alkylating chemotherapeutic agents
- Gross hematuria
- Irritative voiding symptoms
- Pelvic irradiation
- Urologic disorder or disease
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Diagnostic Evaluation
Imaging
Treatment
Medical Therapy
Surgery
Prevention
References
- ↑ Cohen RA, Brown RS (2003) Clinical practice. Microscopic hematuria. N Engl J Med 348 (23):2330-8. DOI:10.1056/NEJMcp012694 PMID: 12788998
- ↑ Davis R, Jones JS, Barocas DA, Castle EP, Lang EK, Leveillee RJ et al. (2012) Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol 188 (6 Suppl):2473-81. DOI:10.1016/j.juro.2012.09.078 PMID: 23098784
- ↑ Rew, Karl (2010). Primary care urology. Philadelphia, Pa. London: Saunders. ISBN 978-1437724899.
- ↑ Rew, Karl (2010). Primary care urology. Philadelphia, Pa. London: Saunders. ISBN 978-1437724899.
- ↑ Loo RK, Lieberman SF, Slezak JM, Landa HM, Mariani AJ, Nicolaisen G et al. (2013) Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria. Mayo Clin Proc 88 (2):129-38. DOI:10.1016/j.mayocp.2012.10.004 PMID: 23312369
- ↑ Rew, Karl (2010). Primary care urology. Philadelphia, Pa. London: Saunders. ISBN 978-1437724899.
- ↑ Sharp VJ, Barnes KT, Erickson BA (2013) Assessment of asymptomatic microscopic hematuria in adults. Am Fam Physician 88 (11):747-54. PMID: 24364522