Hematuria

Hematuria: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ Urinary tract infection

❑ Nephrolithiasis

❑ Anticoagulation

❑ Long distance running

❑ Renal trauma

❑ Bladder cancer

❑ Renal cell cancer

❑ Transitional cell cancer

❑ Glomerulonephritis

❑ Interstitial cystitis

❑ Hemorrhagic cystitis

❑ Hemoglobinuria

❑ Endocarditis

❑ Polycystic kidney disease

❑ Renal artery embolism

❑ Renal vein thrombosis

❑ Endometrial implants

❑ Wegener granulomatosis

❑ Goodpasture syndrome

Diagnostic Approach

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.

Clinical Findings

Urinary tract infection  Cystitis is the most common cause of hematuria. Symptoms are urinary urgency, frequency, and/or burning. Pyuria is the sine qua non.

Nephrolithiasis  The patient presents with acute flank pain that radiates to the testicle or thigh, associated with either microscopic or gross hematuria. The pain is often severe, causing the patient to be restless and diaphoretic.

Anticoagulation  Hematuria in a patient who takes anticoagulants, even if over-anticoagulated, should be investigated for an underlying structural cause.

Long distance running  Evident by history, it can be due to true hematuria or myoglobinuria with a positive dipstick for hemoglobin (peroxidase).

Renal trauma  Suspect with a history of blunt flank trauma.

Bladder cancer  The typical history is one of urinary frequency, penile pain following urination, and the appearance of a few drops of blood after urination.

Renal cell cancer  Renal cancer is usually recognized by painless hematuria with an abdominal mass. The hematuria is intermittently massive. Flank pain may occur with passage of clots.

Transitional cell cancer  Hematuria is the presenting finding in 80% of cases.

Glomerulonephritis  Red cell casts on microscopic examination of the urine are the hallmark. Fever, oliguria, and edema of the legs, back, and eyelids also occur. A recent upper respiratory infection suggests either postinfectious glomerulonephritis or IgA nephropathy.

Interstitial cystitis  It is recognized as frequent painful urination in the absence of infection.

Hemorrhagic cystitis  Cyclophosphamide is a common cause in oncology patients.

Hemoglobinuria  Urine will be dark reddish-brown and the dipstick will be positive without red cells on microscopic examination. Hemolysis results from autoimmune hemolytic anemia, transfusion, paroxysmal nocturnal hemoglobinuria, diffuse intravascular coagulation, hemolytic-uremic syndrome, malaria, and snake or spider bites.

Endocarditis  Inspect for fever, new murmur, or splinter hemorrhages.

Polycystic kidney disease  Bilateral flank masses, polyuria, and a family history of renal failure or polycystic kidneys are present.

Renal artery embolism  Embolism usually occurs in the setting of a murmur or arrhythmia, particularly atrial fibrillation. Sudden in onset, embolism causes a sharp, continuous pain in the flank or upper abdomen.

Renal vein thrombosis  In young adults, acute or subacute deterioration of renal function occurs in the setting of oral contraceptive use, nephrotic syndrome, trauma, or pregnancy. In older adults, hypertension and recurrent pulmonary emboli may be the presenting manifestations.

Endometrial implants  Bleeding is timed to the menstrual cycles.

Wegener granulomatosis  Renal involvement is marked by hematuria and rapidly progressive renal failure. Pulmonary symptoms include cough, hemoptysis, and dyspnea. Upper airway involvement produces purulent or bloody nasal drainage, which leads to septal perforation and/or saddle nose deformity. Other findings can include scleritis, palpable purpura, cranial neuritis, and systemic symptoms of weakness, weight loss, and arthralgias.

Goodpasture syndrome  This syndrome presents more focally with hemoptysis and hematuria with rapidly progressive renal failure.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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