Diagnostic Tests for Hematuria
Hematuria Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Hematuria:
- Bladder & Urinary Health: Home Testing:
- Kidney Health: Home Testing:
Hematuria Diagnosis: Book Excerpts
Tests and diagnosis discussion for Hematuria:
Hematuria (Blood in the Urine): NIDDK (Excerpt)
In order to find the cause of hematuria, or to rule out certain causes,
the doctor may order a series of tests, including urinalysis, blood tests,
intravenous pyelogram, and cystoscopic examination.
Urinalysis is the examination of urine for various cells and chemicals.
In addition to finding RBCs, the doctor may find white blood cells that
signal a urinary tract infection or casts (groups of cells molded together
in the shape of the kidneys' tiny filtering tubes) that signal kidney
disease. Excessive protein in the urine also signals poor kidney function.
Blood tests may reveal kidney disease if the blood contains high levels
of wastes that the kidneys are supposed to remove.
An intravenous pyelogram (IVP) is an x-ray of the urinary tract. An IVP
may reveal a tumor, a kidney or bladder stone, an enlarged prostate, or
other blockage to the normal flow of urine.
A cystoscope can be used to take pictures of the inside of the bladder.
It has a tiny camera at the end of a thin tube, which is inserted through
the urethra. A cystoscope may provide a better view of a tumor or bladder
stone than can be seen with an IVP.
(Source: excerpt from Hematuria (Blood in the Urine): NIDDK)
Cystoscopy and Ureteroscopy: NIDDK (Excerpt)
When you have a urinary problem, your doctor may use a cystoscope to
see the inside of your bladder and urethra. The urethra is the tube that
carries urine from the bladder to the outside of the body. The cystoscope
has lenses like a telescope or microscope. These lenses let the doctor
focus on the inner surfaces of the urinary tract. Some cystoscopes use
optical fibers (flexible glass fibers) that carry an image from the tip of
the instrument to a viewing piece at the other end. The cystoscope is as
thin as a pencil and has a light at the tip. Many cystoscopes have extra
tubes to guide other instruments for procedures to treat urinary problems (Source: excerpt from Cystoscopy and Ureteroscopy: NIDDK)
Kidney Biopsy: NIDDK (Excerpt)
A biopsy is a diagnostic test that involves collecting small pieces of
tissue, usually through a needle, for examination under a microscope. A
kidney biopsy can help find a diagnosis and determine the best course of
treatment. (Source: excerpt from Kidney Biopsy: NIDDK)
Diagnostic Tests for Hematuria: Online Medical Books
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Review excerpts from medical books online, free, without registration,
for more information about the diagnostic tests for Hematuria.
HEMATURIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
The workup begins with a urinalysis and microscopic examination of the urinary sediment. The physician can easily do this in his office. If there is proteinuria, granular cast, and red cell cast, glomerulonephritis or collagen disease should be suspected. A culture and sensitivity and colony count should be done if a UTI is suspected. A three-glass test may be done. If there is blood in the initial specimen, the cause is most likely in the urethra or male genitalia. If it is in the final specimen, the cause is most likely a bladder lesion. Phase-contrast microscopy may also be helpful in identifying hematuria from a glomerular lesion. If this is negative, an anaerobic culture should be done also and then an AFB smear and culture and guinea pig inoculation to rule out tuberculosis. An intravenous pyelogram will also usually have to be done. A CBC, sedimentation rate, chemistry panel, coagulation profile, and ANA test will help rule out blood dyscrasias, collagen diseases, and other systemic diseases. Ultrasonography may help diagnose a renal cyst.
If the above are not revealing, referral to a urologist is indicated. He will probably do a cystoscopy and retrograde pyelography. He may also want to order a CT scan of the abdomen and pelvis and a renal biopsy. Renal angiography and aortography may be necessary to evaluate renovascular hypertension and renal embolism.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
DYSURIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Obviously, a urinalysis and Gram stain of the unspun urine should be done in all cases. If this is positive, treatment can be initiated. Urine cultures are only necessary for resistant or repeated episodes. I also recommend a urethral smear and a vaginal smear and culture if sufficient material can be obtained. This may mean massaging the prostate for an adequate specimen. Even four white cells per high-powered field on a urethral smear probably indicates urethritis. Cultures for both gonorrhea and chlamydia should be done. In persistent cases of dysuria, an intravenous pyelogram and a cystoscopy must be done. A urologist needs to be consulted before ordering these tests. Blood cultures should be done in cases of acute pyelonephritis. Cultures for anaerobic bacilli and tuberculosis may be necessary in persistent pyuria. It should go without saying that a rectal and vaginal examination should be done in all cases. However, this is frequently neglected.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PROTEINURIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
When faced with a report of protein in the urine, the first thing to do is look at the urine under the microscope. If there are significant numbers of bacteria and WBCs, one has only to order a urine culture and colony count and begin therapy. Recurrent UTIs warrant an IVP and a referral to a urologist, especially in males. If no infection is found, a more thorough workup is warranted, including CBC, chemistry panel, serum protein electrophoresis, ANA, sedimentation rate, urine for Bence-Jones protein, Addis count, ASO titer, IVP, and CT scan of the abdomen. A urologist may need to be consulted for cystoscopy and retrograde pyelography. A nephrologist may need to be consulted for renal biopsy and further evaluation.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PYURIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
First, look at the urinary sediment under a microscope. Further workup should include a urine culture and colony count, AFB smear and culture, CBC, sedimentation rate, ANA test, chemistry panel, serum protein electrophoresis, IVP, and a urology consultation. A urologist may do cystoscopy and retrograde pyelography. He may order a CT scan of the abdomen to rule out renal carcinomas and other kidney disease. A nephrologist may need to be consulted in difficult cases. A urologist should be consulted in all cases of recurrent or persistent pyuria.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
FREQUENCY OF URINATION:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
The first thing to do is a urinalysis and examine the urinary sediment. This will help determine if there is a UTI and if there is diabetes or one of the other causes of polyuria. A sterile sample of the urine should be sent to the lab for culture regardless of whether the urinalysis is normal.
If these studies are unremarkable, a 24-hr urine volume is determined. If the urine volume is substantially increased, the workup may proceed for polyuria . If the 24-hr urine volume is normal, a pelvic and rectal examination must be done for a mass that might be pressing on the bladder. Even if the pelvic and rectal exam is negative, pelvic ultrasound may disclose a pelvic mass.
The next step would be to catheterize for residual urine. If the residual urine is large, bladder neck obstruction is probably the problem, and prostatic hypertrophy, median bar hypertrophy, and urethral stricture must be considered.
Further studies include an intravenous pyelogram, cystogram, cystoscopy, and retrograde pyelography, but these should be done in consultation with a urologist. If a spastic neurogenic bladder is suspected, order cystometric tests and a neurology consult.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hematuria:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
After detecting hematuria, take a pertinent health history. If hematuria is macroscopic, ask the patient when he first noticed blood in his urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or end of urination? Has it occurred before? Is the patient passing clots? To rule out artifactitious hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if there’s pain or burning with hematuria episodes.
Ask about recent abdominal or flank trauma. Has the patient been exercising strenuously? Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history, noting anticoagulants or aspirin.
Begin the physical examination by palpating and percussing the abdomen and flanks. Next, percuss the costovertebral angle (CVA) to elicit tenderness. Check the urinary meatus for bleeding or other abnormalities. Using a chemical reagent strip, test a urine specimen for protein. A vaginal or digital rectal examination may be necessary.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Urine cloudiness:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask about symptoms of UTI, such as dysuria; urinary urgency or frequency; or pain in the flank, lower back, or suprapubic area. Also ask about recurrent urinary tract infections or recent surgery or treatment involving the urinary tract.
Obtain a urine sample to check for pus or mucus. (See Peforming the three-glass urine test, page 608.) Using a reagent strip, test for blood, glucose, and pH. Palpate the suprapubic area and flanks for tenderness.
If you note cloudy urine in a patient with an indwelling urinary catheter, especially with concurrent fever, remove the catheter immediately (or change it if the patient must have one in place).
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Vaginal bleeding, postmenopausal:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her periods regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.
Observe the external genitalia, noting the character of any vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient’s breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Hematuria:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
After detecting hematuria, take a pertinent health history. If hematuria is macroscopic, ask the patient when he first noticed blood in his urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or end of urination? Has it occurred before? Is the patient passing any clots? To rule out artifactual hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if pain or burning accompanies the episodes of hematuria.
Ask about recent abdominal or flank trauma. Has the patient been exercising strenuously? Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history, noting the use of anticoagulants or aspirin.
Begin the physical examination by palpating and percussing the abdomen and flanks. Next, percuss the costovertebral angle (CVA) to elicit tenderness. Check the urinary meatus for bleeding or other abnormalities. Using a chemical reagent strip, test a urine specimen for protein. A vaginal or digital rectal examination may be necessary.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Dysuria:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of dysuria, have him describe its severity and location. When did he first notice it? Did anything precipitate it? Does anything aggravate or alleviate it?
Next, ask about previous urinary or genital tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy or urethral dilatation, or had a urinary catheter inserted? Also, ask if he has a history of intestinal disease. Ask the female patient about menstrual disorders and use of products that irritate the urinary tract, such as bubble bath salts, feminine deodorants, contraceptive gels, or perineal lotions. Also ask her about vaginal discharge or pruritus.
During the physical examination, inspect the urethral meatus for discharge, irritation, or other abnormalities. A pelvic or rectal examination may be necessary.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urine cloudiness:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask about symptoms of UTI, such as dysuria; urinary urgency or frequency; and pain in the flank, lower back, or suprapubic area. Also ask the patient if he has had recurrent UTIs or recent surgery or treatment involving the urinary tract.
Obtain a urine specimen to check for pus or mucus. (See How to perform the three-glass urine test, page 777.) Using a reagent strip, test for blood, glucose, and pH. Palpate the suprapubic area and flanks for tenderness.
If you note cloudy urine in a patient with an indwelling urinary catheter, especially if he also has a fever, remove the catheter immediately (or change it if the patient must have one in place).
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Vaginal bleeding, postmenopausal:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her periods regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.
Observe the external genitalia, noting the character of any vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient’s breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Hematuria:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
should focus on signs of systemic disease (fever, rash, lymphadenopathy, joint swelling, and abdominal or pelvic mass), and underlying medical or renal disease (hypertension, edema). Multiple telangiectasias and mucous membrane lesions indicate hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease). An abdominal mass in children requires exclusion of Wilms tumor.
Testing
A. Initial evaluation. Hematuria is usually detected by dipstick or microscopic examination. The dipstick test relies on detecting hemoglobin and should always be confirmed by microscopic examination of the urine sediment. Some controversy exists about the abnormal number of red blood cells in urine. Most clinicians consider more than three to five red blood cells per high power field (40 × lens) as definitely abnormal. When dipstick testing is positive for blood but urine microscopy reveals no red blood cells, hemoglobinuria or myoglobinuria should be considered. The next step is a urine culture. Baseline blood tests include a renal panel, complete blood count with differential, sedimentation rate, prothrombin time, and partial thromboplastin time.
B. Further evaluation is highly dependent on the suspected cause. Further blood tests can include serum complement titer (significant if low), antistreptolysin-O titer (high), antinuclear antibody and extended panels with anti-deoxyribonuclease B titer (high), and hemoglobin electrophoresis. A tuberculin skin test or chest x-ray study can be done to detect tuberculosis. Further tests can include imaging studies and cytology. Intravenous pyelogram and abdominal and pelvic ultrasound or computed tomography scanning may detect malignancies of the various anatomic areas as well as benign conditions such as urolithiasis, obstructive uropathy, renal cysts, parenchymal abnormalities, and nonurinary tract lesions. To complete the workup, send the urine for cytology study and proceed with cystoscopy looking for abnormalities of the urethra and bladder. Biopsies of various areas, including kidney and bladder, and invasive vascular studies may be needed. Unless a diagnosis is made, patients will need referral to subspecialists.
Diagnostic assessment
The key to the diagnosis of hematuria is the clinical history and physical examination. Laboratory and imaging studies only confirm or rule out initial suspicions. The goal is to diagnose a variety of serious illnesses, including malignancies and renal parenchymal diseases. In general, keep in mind that transient hematuria, especially in a young person, is quite common and rarely indicative of significant pathology (4). When present in patients aged more than 50 years, however, transient hematuria always warrants a comprehensive evaluation to rule out malignancy. Similarly, a diagnostic workup should be performed when persistent hematuria is found in patients of any age.
References
1. Froom P, Ribak J, Benbassat J. The significance of microhematuria in young adults. BMJ 1984;288:20–28.
2. Mariani AJ, Mariani MC. The significance of adult hematuria: 1000 hematuria evaluations including a risk-benefit and cost-effectiveness analysis. J Urol 1989;
141:350–355.
3. Messing EM, Young TB, Hunt VB, et al. Hematuria home screening: repeat testing results. J Urol 1995;154(1):57–61.
4. Murakami S, Igarashi T, Hara S, et al. Strategies for asymptomatic microscopic hematuria: a prospective study of 1034 patients. J Urol 1990;144:99–106.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Dysuria:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
The physical examination is essential in narrowing the diagnosis. It helps to rule out pyelonephritis and other systemic infections in patients with dysuria, allowing the physician to search for the less severe causes. Fever, flank tenderness, and suprapubic tenderness are useful findings. A careful genital examination (speculum in women, foreskin retraction and prostate examination in uncircumcised men) can point to specific localized causes. The genital examination also allows collection of samples for testing. Attention to localized lesions (e.g., HSV lesions), discharge (yeast, bacterial vaginosis, gonorrhea, and trichomoniasis) and trauma also help make the diagnosis.
Testing
The history and physical examination usually suggests which tests are most appropriate. A urinalysis is the most common study performed. It is important also to gather samples for gonorrhea, chlamydia, and HSV, using wet preparations and potassium hydroxide testing when appropriate. Rapid tests on urine samples for the detection of bacteria and leukocytes can be done while patients wait. Direct microscopic examination of the urine can isolate bacteria and leukocytes. Rapid dipstick biochemical tests can isolate leukoesterase and nitrate, which are consistent with leukocytes and urea-fixing bacteria. Urine cultures require overnight to 48 hours of incubation to detect specific bacterial pathogens. Pyuria (defined as white blood cell count >10/mm3 of urine) is seen in more than 95% of patients with acute UTI but is uncommon in the absence of infection. Pyuria without bacteriuria suggests a chlamydia infection. Urine dipstick testing is generally less sensitive for pyuria than microscopic examination, but it is more convenient (5).
Diagnostic assessment
Given the many causes of dysuria, an accurate diagnosis can be difficult without a thorough approach to each patient. Because most causes have other associated symptoms and findings, a diagnosis can usually be made with a carefully taken history, a focused physical examination, and appropriate laboratory tests. Separating an uncomplicated UTI or STD from the more serious pyelonephritis and other possible diagnoses is the challenge in these patients.
References
1. Carlson KJ, Mulley AG. Management of acute dysuria. Ann Intern Med 1985;102:
244–249.
2. Johnson JR, Stamm WE. Diagnosis and treatment of acute urinary tract infections. Infect Dis Clin North Am 1987;4(1):773–791.
3. Ainsworth JG, Weaver T, Murphy S, Renton A. General practitioners’ immediate management of men presenting with urethral symptoms. Genitourin Med 1996;72(6):427–430.
4. Roberts RO, Lieber MM, Rhodes R, Girman CJ, Bostwick DG, Jacobsen SJ. Prevalence of a physician-assigned diagnosis of prostatitis: the Olmsted County Study of Urinary Symptoms and Health Status Among Men. Urology 1998;51(4):578–584.
5. Kurowiski K. The woman with dysuria. Am Fam Physician 1998;57(9):2155–2164, 2169–2170.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Postmenopausal Bleeding:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Vital signs. Blood pressure and pulse can indicate the degree and acuity of blood loss; orthostatic changes can be evidence of significant volume depletion. Fever suggests infection as a potential cause (Chapter 2.6).
B. Abdomen. Tenderness or guarding suggests an infectious or inflammatory cause. Palpation for suprapubic masses is necessary as part of the evaluation for malignant causes.
C. Pelvis. Examine external genitalia, vagina, and cervix for lesions or lacerations that could be the source of bleeding. The uterus and ovaries must be palpated to assess for enlargement, masses, and tenderness.
D. Rectum. Rectal examination and anoscopy may be warranted to rule out hemorrhoids or other intestinal source of bleeding (Chapter 9.11).
Testing
A. Office laboratory testing. Urinalysis, stool guaiac testing, or both can be useful to look for nongenital sources of blood. A complete blood count may be helpful in assessing the degree of blood loss and likelihood of infection. Testing for gonorrhea and chlamydia may be warranted when tenderness or fever is present.
B. Pap smear. Many sources recommend a pap smear as part of the evaluation, although its diagnostic yield in these cases is low. Cervical lesions or friability raise the possibility of a cervical bleeding source. Endometrial cells found on the pap smear of a postmenopausal woman not on HRT warrants further evaluation of the endometrium.
C. Biopsy
1. Visible lesions of the vulva, vagina, or cervix should be sent for biopsy.
2. In the absence of a clear nonuterine source of bleeding, endometrial biopsy is usually recommended. This office test can cost-effectively identify endometrial hyperplasia and carcinoma, with a sensitivity of 85% to 95% (3), and it is lower in cost and risk than other procedures (2).
3. Traditional wisdom required dilation and curettage (D&C) for diagnosis if endometrial biopsy was negative. Recent evidence indicates this is unlikely to be of benefit (despite higher risk and cost), except in cases where other procedures are not possible (2–5).
4. If bleeding continues after normal biopsy, consider repeat biopsy or assessment by another method (5).
D. Diagnostic imaging
1. Palpable adnexal abnormalities should be evaluated by ultrasound or other imaging as appropriate.
2. Transvaginal ultrasound (TVUS) is gaining popularity as an alternative or adjunct to endometrial biopsy. A clearly identifiable endometrial stripe less than 4 or 5 mm in thickness is highly unlikely to contain hyperplasia or carcinoma, and biopsy may not be necessary (2,4). Fluid in the endometrial cavity has been associated with carcinoma, and its presence warrants further investigation (5). TVUS should not be used in place of biopsy in women on tamoxifen, as the drug is known to cause misleading ultrasound findings (3,5).
3. Hysteroscopy is becoming the “gold standard” against which other methods of endometrial assessment are compared (4,5). Flexible hysteroscopy allows direct visualization of the endometrium in the office setting, and can be used for directed biopsy and removal of small polyps. Rigid hysteroscopy allows greater intervention, but requires greater anesthesia.
4. Sonohysterography (ultrasound evaluation after instillation of fluid into the endometrial cavity) appears to offer promise as another alternative that provides additional information on the uterine architecture (3,5). This is the subject of ongoing study, especially in comparison with hysteroscopy, which provides similar information and may allow simultaneous biopsy of identified lesions.
Diagnostic assessment
Initial clinical evaluation may identify a nonuterine source. Postcoital spotting in conjunction with vaginal atrophy or cervical friability suggests cervical or vaginal mucosal bleeding. Gross hematuria or visibly bleeding hemorrhoids suggest that the bleeding source is not genital. If no other source is identified, however, the key to diagnosis is imaging and tissue sampling of the endometrium. A thin endometrial stripe in a woman in a low-risk category suggests endometrial atrophy. Findings on biopsy can include atrophy, proliferative changes, various degrees of hyperplasia (simple, complex, and atypical, in increasing order of risk), or carcinoma. If neither biopsy nor TVUS provides sufficient information, hysteroscopy is the recommended next step. D&C should be reserved for cases in which other methods are unsuccessful or unavailable.
References
1. Shelly MS. Endometrial biopsy. Am Fam Physician 1997;55(5):1731–1736.
2. Feldman S, Berkowitz RS, Tosteson ANA. Cost-effectiveness of strategies to evaluate post-menopausal bleeding. Obstet Gynecol 1993;81(6):968–975.
3. O’Connell LP, Fries MH, Zeringue E, Brehm W. Triage of abnormal postmenopausal bleeding: a comparison of endometrial biopsy and transvaginal sonohysterography versus fractional curettage with hysteroscopy. Am J Obstet Gynecol 1998;178(5):956–961.
4. Emanuel MH, Verdel MJ, Wamsteker K, Lammes FB. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in evaluation of patients with abnormal uterine bleeding: clinical implications. Am J Obstet Gynecol 1995;172(2):547–552.
5. Good AE. Diagnostic options for assessment of postmenopausal bleeding. Mayo Clin Proc 1997;72:345–349.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Hematuria:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
A reasonable cutoff for discriminating benign from serious causes of hematuria is 10 RBCs/HPF. The urine dipstick detects as few as 1 to 2 RBCs/HPF. Analysis of the urine sediment is crucial. White cells and bacteria are indicative of cystitis whereas white cell casts are seen in pyelonephritis. Red cell casts and dipstick proteinuria indicate glomerulonephritis. Red cells from a glomerular source tend to be distorted. A positive dipstick for hemoglobin but no RBCs in the urinalysis suggests the presence of myoglobin or free hemoglobin derived from intravascular hemolysis. Menstrual blood contamination needs to be considered in the differential of microscopic hematuria.
Initial hematuria suggests a urethral source; terminal hematuria, the prostatic urethra, trigone, or base; and total hematuria, the kidney, ureter, or bladder. Massive hematuria is usually associated with bladder neoplasm, benign prostatic hypertrophy, or trauma. Bright red urine suggests a lower urinary source. Passage of bulky disc-like or fragmented clots implies the bladder as source, long shoestring clots suggest a ureteral origin, and pyramidal clots are from the renal pelvis. Glomerular sources virtually never produce clots (due to the presence of tissue plasminogen activators in the glomeruli and tubules). With a presentation of painless total hematuria, a urinary tract cancer is found in 20%.
Flank pain associated with hematuria may result from the passage of stones or clots. Hypertension suggests renal disease. Rash, fever, arthralgia/arthritis, or hemoptysis suggests a connective tissue disease or vasculitis. Beets, blackberries, and rhubarb, as well as pyridium, rifampin, phenothiazines, and anthracyclines, can produce red urine without blood.
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Source: Field Guide to Bedside Diagnosis, 2007
Dysuria:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
In women, ask whether burning is internal (urinary tract infection) or external (vaginitis). Women who have had a prior urinary tract infection are more than 90% accurate in identifying recurrences.
The urine dipstick is a useful diagnostic adjunct for determining the presence of pyuria. Leukocyte esterase and nitrate tests are complementary, increasing the overall sensitivity.
Always consider a sexually transmitted infection, especially with minimal pyuria and/or a new sexual partner.
The combination of symptoms of dysuria and frequency without vaginal discharge or irritation has an overall likelihood ratio of 24.6 in predicting acute urinary tract infection.
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Source: Field Guide to Bedside Diagnosis, 2007
Proteinuria:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Proteinuria may present on urinalysis or as edema caused by reduced oncotic pressure from serum albumin loss. The dipstick detects albumin in concentrations of 30 mg/dL (Sensitivity 70%, Specificity 92%, Likelihood ratio 8.8), or 300 to 500 mg of proteinuria per day. False positives may be seen with dehydration and hematuria, both of which can be detected with the dipstick (specific gravity and hemoglobin). False negatives can occur when the protein is a low molecular weight tubular protein (not albumin), e.g., immunoglobulin light chains in myeloma or beta-2 microglobulin. In nephrotic syndrome more than 3.5 grams per day of proteinuria occurs.
Systemic disease should be suspected in the presence of fever, rash, or arthritis.
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Source: Field Guide to Bedside Diagnosis, 2007
Hematuria:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin the physical examination by palpating and percussing the abdomen and flanks. Next, percuss the costovertebral angle (CVA) to elicit tenderness. Check the urinary meatus for bleeding or other abnormalities. Using a chemical reagent strip, test a urine specimen for protein. A vaginal or digital rectal examination may be necessary.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Dysuria:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient to void before beginning your examination. Inspect the urethral meatus for discharge, irritation, and other abnormalities. Then percuss over the kidneys. Costovertebral angle tenderness indicates kidney inflammation. Percuss the bladder. Start at the symphysis pubis and percuss upward. You should hear tympany; a dull sound signals retained urine. Then palpate the kidneys. Normally, they aren’t palpable unless they’re enlarged. If the kidneys feel enlarged, the patient may have hydronephrosis, cysts, or tumors. You won’t be able to palpate the bladder unless it’s distended. (See Palpating the kidneys.) A pelvic or rectal examination may be necessary.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Vaginal bleeding, postmenopausal:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Observe the external genitalia, noting the character of any vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient’s breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hematuria:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
First stepin diagnosis is to determine whether there is blood in urine. Althoughblood may produce pink, red, or brownish color of the urine, othersubstances also may produce same type of urinary discoloration.Urine dipstick detects hemoglobin containedin red cells as well as free Hgb. It can detect as few as 1 or 2red cells per high-power field in uncentrifuged specimen. Microscopydetermines whether red cells are in urine and thus the presenceof hematuria.Urine sample that tests positive ondipstick but negative on microscopy indicates presence of hemoglobinor myoglobin. Serum is pink in color with hemoglobinuria and normalin color with myoglobinuria.Best way to distinguish myoglobin fromHgb is immunochemically. Red, orange, or brownish urine that isdipstick negative for blood indicates that certain foods (blackberries,beets), food dyes, urate crystals, or drugs (pyridium, desferoximine)are coloring urine. Urine containing porphyrin initially has normalcolor but changes to red on standing; dipstick is negative, andno red cells are seen on microscopy. Hematuria without Proteinuria
Microscopichematuria without proteinuria is most commonly due to urinary tractinfection, trauma, acute postinfectious glomerulonephritis, immunoglobulinA nephropathy, familial benign hematuria, or nonfamilial benignhematuria.Following history and physical exam,these tests should be performed initially: UA of child and familymembers (to diagnose familial benign hematuria), urine culture,serum creatinine, blood urea nitrogen, C3, calcium:creatinine ratio,and renal U/S. If results of these tests are normal, andproteinuria is consistently absent, most causes of hematuria havebeen excluded and further diagnostic studies (e.g., cystoscopy andrenal biopsy) are usually unnecessary.Children categorized as having nonfamilialbenign hematuria because they have normal evaluation and no recognizablerenal disease may prove to have transient hematuria, but as longas hematuria occurs, these children should be followed for possibleoccurrence of proteinuria. Those with familial benign hematuriaalso should be followed.In addition to above tests, diagnosticevaluation of gross hematuria should include CBC, platelet count,antistreptolysin O or streptozyme titer, and Hgb electrophoresis(in African-American children). Renal angiography may be necessaryif vascular malformation is suspected. If proteinuria occurs whenhematuria subsides, renal biopsy may be indicated. Hematuria with Proteinuria
Glomerulonephritisshould be suspected in every child with hematuria and proteinuria.Presence of red cell casts indicatesglomerular bleeding.Results of tests for urinary protein(urine dipstick, sulfosalicylic acid test) are usually positivewith gross hematuria. Although dipstick protein reading of 3+ to4+ may signify glomerular disease with gross hematuria,lower reading may have diagnostic significance. See Chap. 50, Proteinuria, forprotein concentrations corresponding to dipstick readings.To more reliably detect proteinuriaassociated with glomerular disease, urine should be tested whengross hematuria subsides.Renal biopsy is required for specificdiagnosis unless there is evidence of unequivocal acute postinfectiousglomerulonephritis or family history of Alport syndrome. Biopsymay be necessary with acute postinfectious glomerulonephritis ifserum C3 level does not become normal within 2 mos, if proteinuriapersists for >6 mos, or to distinguish it from idiopathicrapidly progressive glomerulonephritis if presentation is that ofacute renal failure.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Dysuria:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
History and physical exam are usually diagnosticof trauma, vulvovaginitis, labial adhesions, chemical irritation,and diaper dermatitis. Otherwise, suspect UTI and perform UA andurine culture.
Urinalysis
Presenceof WBCs (>10/high-power field) in sediment ofcentrifuged specimen of urine suggests but is not diagnostic ofUTI. Neither is positive leukocyte esterase test (urine dipstick), whichindicates presence of WBCs in urine.Positive nitrite test using nitritestrip (Griess test) on urine dipstick is highly sensitive and specificfor detection of gram-negative bacteria (e.g., E. coli, Klebsiella,and Proteus species). Positive reaction usually indicates 105 CFUs/mL.False-positive reactions are uncommon if urine is fresh; however,if urine is not examined immediately, test result may be positivebecause of bacteria growing at room temperature. False-negativereactions may occur when there has been inadequate time for bacterialproliferation (random collection rather than first morning specimen)or when infection is due to Enterococcal species and some Staphylococcaland Pseudomonas species that do not convert nitrate to nitrite.Presence of ≥1 bacteria/oilimmersion field of unspun urine (unstained or Gram stain) from clean-catchmidstream specimen correlates with urine colony count of >105 CFUs/mL80–95% of the time. Urine Culture
Quantitative culture of properly collectedurine specimen establishes diagnosis of UTI, and susceptibilitytesting can be performed. Table15.1, based on data from many studies, is useful guidefor diagnosis of UTI.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Proteinuria:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
First stepin evaluation of a child with proteinuria is to determine if thereare any predisposing factors for transient or functional proteinuria(e.g., fever or strenuous exercise).If history is negative for these factorsand dipstick protein is persistently ≥1+, next step isto do complete UA and determine protein:creatinine ratio in a firstmorning spot urine specimen.If results of UA are normal and protein:creatinineratio is in normal range, diagnosis is postural proteinuria andno further studies are necessary.If results of UA are otherwise abnormalor first morning protein:creatinine ratio is above normal, furtherstudies are necessary. Serum electrolytes, creatinine, albumin,and cholesterol as well as blood urea nitrogen should be measured,and renal U/S should be performed. C3 and antinuclear antibody shouldbe considered.If diagnosis remains uncertain andno chemical or radiographic evidence of renal disease exists, renalbiopsy may be performed or child may tentatively be considered tohave benign persistent proteinuria. If renal biopsy is not performedor is normal, child should be monitored at 6-mo intervals for urinaryand chemical changes indicative of renal disease.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Hematuria:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
After detecting hematuria, take a pertinent health history. If hematuria is macroscopic, ask the patient when he first noticed blood in his urine. Does it vary in severity between voidings? Is it worse at the beginning, middle, or end of urination? Has it occurred before? Is the patient passing clots? To rule out artifactitious hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if there's pain or burning with hematuria episodes.
Ask about recent abdominal or flank trauma. Has the patient been exercising strenuously? Note a history of renal, urinary, prostatic, or coagulation disorders. Then obtain a drug history, noting anticoagulants or aspirin.
Begin the physical examination by palpating and percussing the abdomen and flanks. Next, percuss the costovertebral angle (CVA) to elicit tenderness. Check the urinary meatus for bleeding or other abnormalities. Using a chemical reagent strip, test a urine specimen for protein. A vaginal or digital rectal examination may be necessary.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Dysuria:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient complains of dysuria, have him describe its severity and location. When did he first notice it? Did anything precipitate it? Does anything aggravate or alleviate it?
Next, ask about previous urinary or genital tract infections. Has the patient recently undergone an invasive procedure, such as cystoscopy or urethral dilatation, or had a urinary catheter placed? Also ask if he has a history of intestinal disease. Ask the female patient about menstrual disorders and the use of products that irritate the urinary tract, such as bubble bath salts, feminine deodorants, contraceptive gels, or perineal lotions. Also ask her about vaginal discharge or pruritus.
During the physical examination, inspect the urethral meatus for discharge, irritation, or other abnormalities. A pelvic or rectal examination may be necessary.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urine cloudiness:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask about symptoms of UTI, such as dysuria; urinary urgency or frequency; or pain in the flank, lower back, or suprapubic area. Also ask about recurrent UTIs or recent surgery or treatment involving the urinary tract. Obtain a complete drug history.
Obtain a urine specimen to check for pus or mucus. (See Performing the three-glass urine test, page 613.) Using a reagent strip, test for blood, glucose, and pH. Palpate the suprapubic area and flanks for tenderness.
If you note cloudy urine in a patient with an indwelling urinary catheter, especially with concurrent fever, remove the catheter immediately (or change it if the patient must have one in place).
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Vaginal bleeding, postmenopausal:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Determine the patient's age and her age at menopause. Ask when she first noticed the abnormal bleeding then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her menses regular? If not, ask her to describe menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient's mother and ask about a family history of gynecologic cancer. Determine whether the patient has associated symptoms and if she's taking estrogen.
Observe the external genitalia, noting the character of vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient's breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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