Sandbox:Hematuria overview

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.

Definition

Hematuria is the presence of blood cells in the urine. Gross hematuria is when blood is visible in the urine. Microscopic hematuria is defined as 3 or more red blood cells per high-powered field in a properly collected urine sample.

classification

Classification by the extent of hematuria

1. Dipstick hematuria: Detection of hemoglobin within red blood cells using reagent strips in macroscopically normal urine.This describes the use of reagent strips to detect blood chemically within urine.
2. Microscopic hematuria: Defined as the presence of more than two to five red blood cells per high powered field within macroscopically normal urine on a properly collected urinary specimen in the absence of an obvious benign cause.
3. Macroscopic hematuria: Defined as the presence of blood in urine that is visible with naked eye.

Classification by the visibility of hematuria

1. Visible hematuria: Also known as Frank hematuria/ Macroscopic hematuria/ Gross hematuria. Visible hematuria can be visualized with the naked eye and is also known as frank, gross or macroscopic hematuria. Visible hematuria is more likely to be associated with malignancy.
   1. Initial hematuria: May indicate urethral pathology
   2. Terminal hematuria: Hematuria at the end of the stream that comes from the proximal urethra (bladder neck/prostate).
   3. Complete hematuria: Hematuria throughout the entire stream suggests bladder, ureteric or renal pathology.
2. Non-visible hematuria: Non-visible hematuria encompasses dipstick and microscopic hematuria.

Classification by the duration of hematuria

1. Transient hematuria: A single urinalysis with hematuria is common and can result from menstruation, viral illness, allergy, exercise, fever, or mild trauma.
2. Persistent or Significant hematuria: >3 RBCs/HPF on three urinalyses, a single urinalysis with >100 RBCs, or gross hematuria.

Causes

Life Threatening Causes

• Intraperitoneal bladder rupture

• Ureteroarterial fistula

• Hemorrhagic cystitis

• Heart failure

• Malignant hypertension

• Shock

Common Causes

• Benign prostatic hyperplasia

• Bladder cancer

• Exercise

• Nephrolithiasis

• Polycystic kidney disease

• Prostate carcinoma

• Renal carcinoma

• Trauma

• Urinary tract infections

Causes by Organ System

Cardiovascular	Arteriosclerosis, arteriovenous malformations, endocarditis, cholesterol embolism, heart failure, hypertension, malignant hypertension, shock
Chemical / poisoning
Dermatologic	Hereditary hemorrhagic telangiectasis, lupus, Osler's disease, systemic lupus erythematosus, urethral carbuncle
Drug Side Effect	Artemether and lumefantrin, beractant, BCG vaccine, bicalutamide, caspofungin acetate, cefpodoxime, cobimetinib, cyclophosphamide,dicoumarol, ethacrynic acid, febuxostat, felbamate, flurbiprofen, gemcitabine, goserelin, hexaminolevulinate, Ibrutinib, Indinavir, Ifosfamide, Ioxilan, leuprolide, methenamine, micafungin, mitotane, olsalazine, Oxcarbazepine, Oxaprozin penicillamine, phenprocoumon, Pramipexole, probenecid, sodium aurothiomalate, sulfasalazine, tiagabine, tolmetin, tiaprofenic acid, warfarin
Ear Nose Throat	Hereditary hemorrhagic telangiectasis, mononucleosis, Osler's disease
Endocrine	Diabetes mellitus, diabetic glomerulosclerosis, diabetic nephropathy, porphyria
Environmental
Gastroenterologic	Hepatitis B, porphyria
Genetic	Alport syndrome, Berger's disease, Fabry disease, Dent's disease, hemoglobinopathy, hemophilia, IgA nephropathy nail-patella syndrome, Nephrolithiasis type 2Osler's disease, paroxysmal nocturnal haemoglobinuria, polycystic kidney disease, thalassemia,renal arteriovenous malformation, thalassemia
Hematologic	Cold agglutinins, March haemoglobinuria, hemoglobinopathy, hemophilia, hemolytic uremic syndrome, Henoch schonlein purpura, hereditary hemorrhagic telangiectasis, multiple myeloma, paroxysmal cold haemoglobinuria, paroxysmal nocturnal haemoglobinuria, polycythemia vera, porphyria, sickle cell anemia, thalassemia, thrombocytopeniathrombotic thrombocytopenic purpura
Iatrogenic
Infectious Disease	Acute cystitis, acute interstitial nephritis, acute prostatitis, adenovirus, bilharziosis, bladder tuberculosis, chronic cystitis, cystitis, cytomegalovirus, dengue, Dent's disease, E.coli, ECHO viruses endocarditis, filaria, hepatitis B, Influenza, legionella infection, legionella pneumophila, malaria, micafungin mononucleosis, mycoplasma, nephritis, postinfectious glomerulonephritis, prostate tuberculosis, prostatitis pyelonephritis, radiation cystitis, renal tuberculosis, salmonellaschistosomiasis, toxoplasma, trichinella spiralis, tuberculosis, urethritis, vasculitis, pseudomonas, renal tuberculosis, salmonella, schistosomiasis, torulopsis, toxoplasma, trichinella spiralis, tuberculosis, ureter tuberculosis, urethritis, urinary tract infection. urogential tuberculosis
Musculoskeletal / Ortho	Pelvic fracture
Neurologic	Arteriosclerosis, arteriovenous malformations, hereditary hemorrhagic telangiectasis, Osler's disease
Nutritional / Metabolic	Diabetes mellitus Fabry disease
Obstetric/Gynecologic	Endometriosis
Oncologic	Angiomyolipoma, bladder cancer, hypernephroma, multiple myeloma, polycythemia vera, prostate adenoma, prostate cancer, renal adenocarcinoma, renal angiomyolipoma, renal arteriovenous malformation, renal pelvis carcinoma, ureter carcinoma, urethra carcinoma, urothelium carcinoma, Wilms' tumor
Opthalmologic
Overdose / Toxicity
Psychiatric
Pulmonary	Allergic granulomatosis, sarcoidosis, Wegener's granulomatosis
Renal / Electrolyte	Acute cystitis, acute interstitial nephritis Alport syndrome, analgesic nephropathy, Balkan nephropathy, beeturia benign familial hematuria, Berger's disease, calyx diverticulum, cholesterol embolism, chronic cystitis, crescentic glomerulonephritis, cystitis, dense deposit disease, Dent's disease, diabetic glomerulosclerosis, diabetic nephropathy, focal glomerulotnephritis, glomerulonephritis, fibronectin glomerulopathy, hemolytic uremic syndrome, Henoch schonlein purpura, hydronephrosis hypernephroma, IgA nephropathy, Interstitial cystitis, kidney amyloidosis, Loin pain hematuria syndrome,lupus, medullary sponge kidney, membranoproliferative glomerulonephritis, mesangiocapillary glomerulonephritis type iii nephrocalcinosis, nephrolithiasis, nutcracker syndrome, papillary necrosis, polycystic kidney disease, postinfectious glomerulonephritis, post-streptococcal glomerulonephritis, proteinuria, pyelonephritis, radiation nephropathy, renal adenocarcinoma, renal angiomyolipoma, renal artery aneurysm, renal cell carcinoma, renal cyst, renal hyperplasia, renal infarct, renal metastases, renal oncocytoma, renal oncocytoma, renal pelvis carcinoma, renal trauma, renal tuberculosis, renal vein infarct, renal vein thrombosis, shunt nephritis, sponge kidney, systemic lupus erythematosus, thin basement membrane disease, tubulointerstitial nephropathies, urate nephropathy,ureter carcinoma, ureter tuberculosis, urinary tract infection, vesico-ureteral-renal reflux, Wegener's granulomatosis, Wilms' tumor
Rheum / Immune / Allergy	Allergic granulomatosis, Cd59 antigen deficiency, Cold agglutinins, dermatosclerosis, Henoch schonlein purpura, microscopic polyangiitis, polyarteritis nodosa, sarcoidosis, systemic lupus erythematosus, Wegener's granulomatosis
Sexual
Trauma	Pelvic fracture
Urologic	Acute prostatitis, beeturia, benign prostatic hyperplasia, bladder cancer, bladder tuberculosis Dent's disease, foreign body in urethra, hemorrhage from bladder outlet, hemorrhage from urethra hydronephrosis, interstitial cystitis, Loin pain hematuria syndrome, malignancies of the bladder, meatus stenosis, megaureter, polycystic kidney disease, prostate adenoma, prostate cancer, prostate hyperplasia, prostate tuberculosis, prostatectomy, radiation cystitis, urethra carcinoma, urethral carbuncle, urethritis, urinary stones, urinary tract infection, urogential tuberculosis, urolithiasis, urothelium carcinoma
Miscellaneous	Dioctophyma renale, exercise, fistula, foods, Inflammation, infundibulopelvic dysgenesis, Injury, masturbation myoglobinuria, toxins, trauma, tumor, urethral catheterization, urinary catheterization

Causes in Alphabetical Order

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4

Differentiating Hemoglobinuria from Myoglobinuria

Centrifuse Result

Sediment Red

Supernatant Red

Hematuria

Dipstick heme

Negative

Positive

❑ Beeturia ❑ Phenazopyridine ❑ Porphyria ❑ Other

❑ Myoglobin ❑ Hemoglobin

Plasma color

Clear

Red

Myoglobinuria

Hemoglobinuria