Hematuria
Hematuria: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
A cardinal sign of renal and urinary tract disorders, hematuria is the abnormal presence of blood in the urine. Strictly defined, it means three or more red blood cells (RBCs) per high-power microscopic field in the urine. Microscopic hematuria is confirmed by an occult blood test, whereas macroscopic hematuria is immediately visible. However, macroscopic hematuria must be distinguished from pseudohematuria. (See Confirming hematuria.) Macroscopic hematuria may be continuous or intermittent, is often accompanied by pain, and may be aggravated by prolonged standing or walking.
Hematuria may be classified by the stage of urination it predominantly affects. Bleeding at the start of urination—initial hematuria—usually indicates urethral pathology; bleeding at the end of urination—terminal hematuria—usually indicates pathology of the bladder neck, posterior urethra, or prostate; bleeding throughout urination—total hematuria—usually indicates pathology above the bladder neck.
Hematuria may result from one of two mechanisms: rupture or perforation of vessels in the renal system or urinary tract, or impaired glomerular filtration, which allows RBCs to seep into the urine. The color of the bloody urine provides a clue to the source of the bleeding. Generally, dark or brownish blood indicates renal or upper urinary tract bleeding, whereas bright red blood indicates lower urinary tract bleeding.
Although hematuria usually results from renal and urinary tract disorders, it may also result from certain GI, prostate, vaginal, or coagulation disorders or from the effects of certain drugs. Invasive therapy and diagnostic tests that involve manipulative instrumentation of the renal and urologic systems may also cause hematuria. Nonpathologic hematuria may result from fever and hypercatabolic states. Transient hematuria may follow strenuous exercise. (See Hematuria: Causes and associated findings, pages 412 to 415.)
History and physical examination
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.
Medical causes
Appendicitis
About 15% of patients with appendicitis have either microscopic or macroscopic hematuria accompanied by bladder tenderness, dysuria, and urinary urgency. More typical findings include constant right-lower-quadrant pain (especially over McBurney’s point), nausea and vomiting, anorexia, abdominal rigidity, rebound tenderness, constipation, tachycardia, and low-grade fever.
Bladder cancer
A primary cause of gross hematuria in men, bladder cancer may also produce pain in the bladder, rectum, pelvis, flank, back, or leg. Other common features are nocturia, dysuria, urinary frequency and urgency, vomiting, diarrhea, and insomnia.
Bladder trauma
A characteristic finding in traumatic rupture or perforation of the bladder, gross hematuria is typically accompanied by lower abdominal pain. The patient may also develop anuria despite a strong urge to void; swelling of the scrotum, buttocks, or perineum; and signs of shock, such as tachycardia and hypotension.
Calculi
Both bladder and renal calculi produce hematuria, which may be associated with signs of urinary tract infection, such as dysuria and urinary frequency and urgency. Bladder calculi may also cause gross hematuria, referred pain to the lower back or penile or vulvar area and, occasionally, bladder distention.
Renal calculi may produce microscopic or gross hematuria. The cardinal symptom, though, is colicky pain that travels from the CVA to the flank, suprapubic region, and external genitalia when a calculus is passed. The pain may be excruciating at its peak. Other signs and symptoms may include nausea and vomiting, restlessness, fever, chills, abdominal distention and, possibly, decreased bowel sounds.
Coagulation disorders
Macroscopic hematuria is commonly the first sign of hemorrhage in coagulation disorders, such as thrombocytopenia or disseminated intravascular coagulation. Among other features are epistaxis, purpura (petechiae and ecchymosis), and signs of GI bleeding.
Cortical necrosis (acute)
Accompanying gross hematuria in this renal disorder are intense flank pain, anuria, leukocytosis, and fever.
Cystitis
Hematuria is a telling sign in all types of cystitis. Bacterial cystitis usually produces macroscopic hematuria with urinary urgency and frequency, dysuria, nocturia, and tenesmus. The patient complains of perineal and lumbar pain, suprapubic discomfort, and fatigue and occasionally has a low-grade fever.
More common in women, chronic interstitial cystitis occasionally causes gross hematuria. Associated features include urinary frequency, dysuria, nocturia, and tenesmus. Both microscopic and macroscopic hematuria may occur in tubercular cystitis, which may also cause urinary urgency and frequency, dysuria, tenesmus, flank pain, fatigue, and anorexia. Viral cystitis usually produces hematuria, urinary urgency and frequency, dysuria, nocturia, tenesmus, and fever.
Diverticulitis
When this disorder involves the bladder, it usually causes microscopic hematuria, urinary frequency and urgency, dysuria, and nocturia. Characteristic findings include left-lower-quadrant pain, abdominal tenderness, constipation or diarrhea and, occasionally, a palpable, firm, fixed, and tender abdominal mass. The patient may also develop mild nausea, flatulence, and a low-grade fever.
Endocarditis (subacute infective)
Occasionally, this disorder produces embolization, resulting in renal infarction and microscopic or gross hematuria. Common related findings are constant fever, chills, night sweats, fatigue, pallor, anorexia, weight loss, polyarthralgia, petechiae, flank pain, severe back pain, stiff neck, cardiac murmurs, tachycardia, and splenomegaly.
Glomerulonephritis
Acute glomerulonephritis usually begins with gross hematuria that tapers off to microscopic hematuria and RBC casts, which may persist for months. It may also produce oliguria or anuria, proteinuria, mild fever, fatigue, flank and abdominal pain, generalized edema, increased blood pressure, nausea, vomiting, and signs of lung congestion, such as crackles and a productive cough.
Chronic glomerulonephritis usually causes microscopic hematuria accompanied by proteinuria, generalized edema, and increased blood pressure. Signs and symptoms of uremia may also occur in advanced disease.
Nephritis (interstitial)
Typically, this infection causes microscopic hematuria. However, some patients with acute interstitial nephritis may develop gross hematuria. Other findings are fever, maculopapular rash, and oliguria or anuria. In chronic interstitial nephritis, the patient has dilute—almost colorless—urine that may be accompanied by polyuria and increased blood pressure.
Nephropathy (obstructive)
This disorder may cause microscopic or macroscopic hematuria, but urine is rarely grossly bloody. The patient may report colicky flank and abdominal pain, CVA tenderness, and anuria or oliguria that alternates with polyuria.
Polycystic kidney disease
This hereditary disorder may cause recurrent microscopic or gross hematuria. It commonly produces no symptoms before age 40 but may cause increased blood pressure, polyuria, dull flank pain, and signs of urinary tract infection, such as dysuria and urinary frequency and urgency. Later, the patient develops a swollen, tender abdomen and lumbar pain that’s aggravated by exertion and relieved by lying down. He may also have proteinuria and colicky abdominal pain from the ureteral passage of clots or calculi.
Prostatic hyperplasia (benign)
About 20% of patients with an enlarged prostate have macroscopic hematuria, usually when a significant obstruction is present. The hematuria is usually preceded by diminished urinary stream, tenesmus, and a feeling of incomplete voiding. It may be accompanied by urinary hesitancy, frequency, and incontinence; nocturia; perineal pain; and constipation. Inspection reveals a midline mass representing the distended bladder; rectal palpation reveals an enlarged prostate.
Prostatitis
Whether acute or chronic, prostatitis may cause macroscopic hematuria, usually at the end of urination. It may also produce urinary frequency and urgency and dysuria followed by visible bladder distention.
Acute prostatitis also produces fatigue, malaise, myalgia, polyarthralgia, fever with chills, nausea, vomiting, perineal and low back pain, and decreased libido. Rectal palpation reveals a tender, swollen, boggy, firm prostate.
Chronic prostatitis commonly follows an acute attack. It may cause persistent urethral discharge, dull perineal pain, ejaculatory pain, and decreased libido.
Pyelonephritis (acute)
This infection typically produces microscopic or macroscopic hematuria that progresses to gross hematuria. After the infection resolves, microscopic hematuria may persist for a few months. Related signs and symptoms include persistent high fever, unilateral or bilateral flank pain, CVA tenderness, shaking chills, weakness, fatigue, dysuria, urinary frequency and urgency, nocturia, and tenesmus. The patient may also exhibit nausea, vomiting, anorexia, and signs of paralytic ileus, such as hypoactive or absent bowel sounds and abdominal distention.
Renal cancer
The classic triad of signs and symptoms includes gross hematuria; dull, aching flank pain; and a smooth, firm, palpable flank mass. Colicky pain may accompany the passage of clots. Other findings include fever, CVA tenderness, and increased blood pressure. In advanced disease, the patient may develop weight loss, nausea and vomiting, and leg edema with varicoceles.
Renal infarction
Typically, this disorder produces gross hematuria. The patient may complain of constant, severe flank and upper abdominal pain accompanied by CVA tenderness, anorexia, and nausea and vomiting. Other findings include oliguria or anuria, proteinuria, hypoactive bowel sounds and, a day or two after the infarction, fever and increased blood pressure.
Renal papillary necrosis (acute)
This disorder usually produces gross hematuria, which may be accompanied by intense flank pain, CVA tenderness, abdominal rigidity and colicky pain, oliguria or anuria, pyuria, fever, chills, vomiting, and hypoactive bowel sounds. Arthralgia and hypertension are common.
Renal trauma
About 80% of patients with renal trauma have microscopic or gross hematuria. Accompanying signs and symptoms may include flank pain, a palpable flank mass, oliguria, hematoma or ecchymosis over the upper abdomen or flank, nausea and vomiting, and hypoactive bowel sounds. Severe trauma may precipitate signs of shock, such as tachycardia and hypotension.
Renal tuberculosis
Gross hematuria is often the first sign of this disorder. It may be accompanied by urinary frequency, dysuria, pyuria, tenesmus, colicky abdominal pain, lumbar pain, and proteinuria.
Renal vein thrombosis
Gross hematuria usually occurs in this type of thrombosis. In an abrupt venous obstruction, the patient experiences severe flank and lumbar pain as well as epigastric and CVA tenderness. Other features include fever, pallor, proteinuria, peripheral edema and, when the obstruction is bilateral, oliguria or anuria and other uremic signs. The kidneys are easily palpable. Gradual venous obstruction causes signs of nephrotic syndrome, proteinuria and, occasionally, peripheral edema.
Schistosomiasis
This infection usually causes intermittent hematuria at the end of urination. It may be accompanied by dysuria, colicky renal and bladder pain, and palpable lower abdominal masses.
Sickle cell anemia
In this hereditary disorder, gross hematuria may result from congestion of the renal papillae. Associated signs and symptoms may include pallor, dehydration, chronic fatigue, polyarthralgia, leg ulcers, dyspnea, chest pain, impaired growth and development, hepatomegaly and, possibly, jaundice. Auscultation reveals tachycardia and systolic and diastolic murmurs.
Systemic lupus erythematosus
Gross hematuria and proteinuria may occur when this disorder involves the kidneys. Cardinal features include nondeforming joint pain and stiffness, a butterfly rash, photosensitivity, Raynaud’s phenomenon, seizures or psychoses, recurrent fever, lymphadenopathy, oral or nasopharyngeal ulcers, anorexia, and weight loss.
Urethral trauma
Hematuria may occur initially, possibly with blood at the urinary meatus, local pain, and penile or vulvar ecchymosis.
Vaginitis
When this infection spreads to the urinary tract, it may produce macroscopic hematuria. Related signs and symptoms may include urinary frequency and urgency, dysuria, nocturia, perineal pain, pruritus, and a malodorous vaginal discharge.
Vasculitis
Hematuria is usually microscopic in this disorder. Associated signs and symptoms include malaise, myalgia, polyarthralgia, fever, increased blood pressure, pallor and, occasionally, anuria. Other features, such as urticaria and purpura, may reflect the etiology of vasculitis.
Other causes
Diagnostic tests
Renal biopsy is the diagnostic test most often associated with hematuria. This sign may also result from biopsy or manipulative instrumentation of the urinary tract, as in cystoscopy.
Drugs
Drugs that commonly cause hematuria are anticoagulants, aspirin (toxicity), analgesics, cyclophosphamide, metyrosine, penicillin, rifampin, and thiabendazole.
Herb Alert
When taken with an anticoagulant, herbal medicines such as garlic and ginkgo biloba can cause excessive bleeding and hematuria.
Treatments
Any therapy that involves manipulative instrumentation of the urinary tract, such as transurethral prostatectomy, may cause microscopic or macroscopic hematuria. After a kidney transplant, a patient may experience hematuria with or without clots, which may require indwelling urinary catheter irrigation.
Special considerations
Because hematuria may frighten and upset the patient, be sure to provide emotional support. Check his vital signs at least every 4 hours and monitor intake and output, including the amount and pattern of hematuria. If the patient has an indwelling urinary catheter in place, ensure its patency and irrigate it if necessary to remove clots and tissue that may impede urine drainage. Administer prescribed analgesics, and enforce bed rest as indicated. Prepare the patient for diagnostic tests, such as blood and urine studies, cystoscopy, and renal X-rays or biopsy.
Pediatric pointers
Many of the causes described above also produce hematuria in children. However, cyclophosphamide is more likely to cause hematuria in children than in adults.
Common causes of hematuria that chiefly affect children include congenital anomalies, such as obstructive uropathy and renal dysplasia; birth trauma; hematologic disorders, such as vitamin K deficiency, hemophilia, and hemolytic-uremic syndrome; certain neoplasms, such as Wilms’tumor, bladder cancer, and rhabdomyosarcoma; allergies; and foreign bodies in the urinary tract. Artifactual hematuria may result from recent circumcision.
Geriatric pointers
Evaluation of hematuria in elderly patients should include a urine culture, excretory urography or sonography, and consultation with a urologist.
Patient counseling
Teach the patient how to collect serial urine specimens using the three-glass technique. This technique helps determine whether hematuria marks the beginning, end, or entire course of urination.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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