Diseases » Oliguria

Hematuria

Hematuria: Excerpt from In a Page: Signs and Symptoms

Hematuria is the intermittent or persistent excretion of red or brown urine that can occur with a variety of clinical symptoms. The amount of blood can be grossly evident or microscopic. About 2.5% of the general population has asymptomatic hematuria. It is important to evaluate the cause of hematuria, since gross painless hematuria is considered a urinary tract cancer until proven otherwise (even though a malignancy is found in only 10% of cases of hematuria in outpatient populations).

Differential Diagnosis

• Transient hematuria
  –Urinary tract infection/pyelonephritis
  –Nephrolithiasis (kidney or bladder stones)
  –Exercise
  –Trauma, instrumentation, catheterization, or foreign bodies
  –Endometriosis
  –Transient unexplained
  –Henoch-Schönlein purpura/HUS
  –Coagulopathy and excess anticoagulation
  –Prostatitis, epididymitis

Persistent hematuria
–Sickle cell anemia
–Cancer (prostate, bladder, kidney)
–Benign prostatic hypertrophy
–Polycystic kidney disease
–Intrinsic glomerular disease

Other causes of red or brown urine (pseudohematuria)
–Beeturia (14% population are susceptible after eating beets): Due to excretion of betalaine, a reddish pigment
–Myoglobinuria: Rapidly filtered and excreted; source is usually due to rhabdomyolysis; look for increased elevation of plasma CPK levels
–Hemoglobinuria: Occurs when the filtered load of unbound dimer exceeds resorptive capacity of the proximal tubules, generally at serum levels >100–150 mg/dL

Urethral carbuncle

Urethritis (e.g., Chlamydia)

Porphyria

Phenazopyridine (bladder analgesic): Produces an orange color in urine

Postinfectious glomerulonephropathy

Hereditary (Alport's syndrome)

IgA nephropathy (Berger's disease): Often see gross hematuria without positive family history of disease

Loin pain hematuria syndrome

Thin basement membrane disease (benign familial hematuria): Usually see microscopic hematuria; gross hematuria or renal failure is rare

Hypercalciuria or hyperuricuria

Arteriovenous malformation

Fistula

Others include food dyes, phenolphthalein, rifampin, and porphyrins

Excessive anticoagulation

Trauma

Workup and Diagnosis

• History and physical examination
• Urinalysis in all patients (consider catheterization to distinguish vaginal bleeding from other sources)
  –Blood clots occur with extraglomerular sources
  –Glomerular source of bleeding results in RBC casts, large amounts of protein, dysmorphic RBCs
  –UTI results in pyuria, nitrates, leukocyte esterase
  • Initial labs include BUN/creatinine, electrolytes, calcium, uric acid, CBC, and PT/PTT
  • Centrifuge urine sample: Red sediment only suggests hematuria (RBCs in the urine); heme-negative red supernatant suggests hemoglobinuria; heme-positive clear supernatant suggests myoglobinuria
  • Three-tube test: #1, collect first few mL of urine; #2, midstream; #3, last few mL
    –Hematuria in #1 suggests urethral lesion; in #3, bladder trigone lesion; equally in all three, diffuse lesion
  • IVP (contraindicated in dye allergy), renal ultrasound, or spiral CT to evaluate for stones and renal masses
  • Urine cytology and cystoscopy for patients at risk for bladder cancer (e.g., smoking, cyclophosphamide)
  • Consider C3 level, ANA, ANCA, Anti-GBM, ASO, cryoglobulins, and hepatitis C antibodies
  • Renal biopsy if persistent hematuria with negative workup and evidence of progression (increasing proteinuria, creatinine, and blood pressure)

  Treatment

  • Older patients with transient hematuria should always be evaluated due to increased risk of urinary tract cancers; refer to urologist for further evaluation and treatment
  • UTI: Start appropriate antibiotics and follow up with urinalysis to see if hematuria resolves
  • Glomerular sources (RBC casts, protein excretion >500 mg/dL, dysmorphic RBCs): Follow BUN/creatinine, blood pressure, creatinine clearance, and 24-hour urine protein, and refer for biopsy if worsening
  • Nonglomerular source (no RBC casts or dysmorphic RBCs in the urine): Urologic consult if imaging indicates a lesion (renal, bladder, or urethral)
  • Stones: Increase hydration, analgesics, urology referral for large or persistent stones
  • Myoglobinuria/hemoglobinuria: Treat underlying cause
  • Beeturia: Evaluate for iron deficiency or achlorhydria due to pernicious anemia, as treating these disorders may eliminate beeturia; eating foods high in oxalate (spinach, oysters) with beets can also cause beeturia

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

More About Oliguria

• Back to disease: Oliguria: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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