Hematuria resident survival guide

Hematuria Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Tayyaba Ali, M.D.[2]

Overview

Presence of >5 red blood cells (RBCs) per high-power microscopic field in the urine is called hematuria. It can have either benign or malignant etiology. Patients with hematuria could be asymptomatic. Therefore, all patients presenting with a single episode of haematuria require urgent investigation. Microscopic hematuria, or microhematuria (MH), is defined as the presence of RBC 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.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Intraperitoneal bladder rupture

• Ureteroarterial fistula

• Hemorrhagic cystitis

• Heart failure

• Malignant hypertension

• Shock

Common Causes

Children	Age <50 years	Age >50 years
Urinary tract infection Benign familial hematuria or Thin basement membrane disease IgA nephropathy Idiopathic hypercalciuria Transient unexplained	Urinary tract infection Transient unexplained Stones Exercise Trauma Polycystic kidney disease	Urinary tract infection Transient unexplained Stones Benign prostatic hyperplasia Bladder cancer Renal carcinoma Prostate cancer

Diagnosis

The approach to diagnosis of hematuria is based on a step-wise testing strategy. Below is an algorithm summarising the identification and laboratory diagnosis of hematuria.

Seek proper history: ❑ Onset ❑ Progression ❑ Pain/burning on urination ❑ Fever ❑ Abdominal pain/flank pain ❑ Polyuria, frequency ❑ Straining during urination ❑ Nocturia ❑ Weak stream ❑ Dribbling

Examine the patient: ❑ Tachypnea ❑ Cold and clammy skin ❑ Hypotension ❑ HEENT signs: Conjunctival pallor Jaundice ❑ Cardiovascular exam: Tachycardia ❑ Abdominal exam: Costovertebral angle (CVA) tenderness ❑ skin exam: Look for rash ❑ Musculoskeletal exam: Joint pain

Initial workup for hematuria: ❑ Complete blood count (CBC) with differential ❑ Urinalysis, urine strain, and culture ❑ Blood urea nitrogen:creatinine (BUN:Cr) ❑ Ultrasound (U/S) and CT abdomen ❑ Cystoscopy

Urine dipstick positive for heme: Does microscopic urinalysis reveal >3 RBC/HPF? ❑ Yes (Consider hematuria) ❑ No (Causes include free urinary hemoglobin (from intravascular hemolysis), or free urinary myoglobin (from rhabdomyolysis). In men, the presence of semen in the urine sample may produce a positive dipstick from heme.)

Initial hematuria: (Blood at beginning of micturition with subsequent clearing) Consider differential diagnosis: ❑ Urethritis ❑ Trauma (e.g, catheterization)

Terminal hematuria: (Blood seen at end of micturition after initial voiding of clear urine) Consider differential diagnosis: ❑ Urothelial cancer ❑ Cystitis (Infectious/post radiation) ❑ Urotheliasis ❑ Benign prostatic hypertrophy ❑ Prostate cancer

Total hematuria: (Blood visible throughout micturition) Consider differential diagnosis: ❑ Renal mass (benign/malignant) ❑ Glomerulonephritis ❑ Urolithiasis ❑ Polycystic kidney disease ❑ Pyelonephritis ❑ Urothelial cancer ❑ Trauma

Treatment

The management of hematuria will depend on the underlying cause. Click on each disease shown below to see detail management for every cause of hematuria.

Initial hematuria: (Blood at beginning of micturition with subsequent clearing)	Terminal hematuria: (Blood seen at end of micturition after initial voiding of clear urine)	Total hematuria: (Blood visible throughout micturition)
❑ STEMI / LBBB ❑ NSTEMI / Unstable angina ❑ Stable angina ❑ Pericarditis ❑ Aortic dissection ❑ Aortic stenosis ❑ Prinzmetal's angina ❑ PCI-induced coronary vasospasm ❑ Cocaine induced coronary vasospasm	❑ Pulmonary embolism ❑ Pneumothorax ❑ Asthma exacerbation ❑ Pulmonary hypertension ❑ Pneumonia ❑ Pleuritis	❑ Pancreatitis ❑ Acute cholecystitis ❑ GERD ❑ Peptic ulcer ❑ Esophageal spasm ❑ Mallory-Weiss syndrome	❑ Musculoskeletal pain: ❑ Costochondritis ❑ Rheumatoid arthritis ❑ Rib fracture ❑ Herpes zoster ❑ Anxiety ❑ Panic disorder

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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