Diagnosis of Pyelonephritis
Diagnostic Test list for Pyelonephritis:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Pyelonephritis
includes:
Pyelonephritis Diagnosis: Book Excerpts
Tests and diagnosis discussion for Pyelonephritis:
Diagnosis is made with a urine test to identify bacteria and formations
of white blood cells, called casts, shaped like tubes in the kidneys. If
an infection cannot be easily cured, x-rays might be done to look for
abnormalities in the kidneys, ureters, and bladder.
(Source: excerpt from Pyelonephritis (Kidney Infection) in Adults: NIDDK)
Diagnosis of Pyelonephritis: medical news summaries:
The following medical news items
are relevant to diagnosis and misdiagnosis issues for Pyelonephritis:
Diagnostic Tests for Pyelonephritis: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Pyelonephritis.
HEMATURIA:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there abdominal pain? The presence of abdominal pain with hematuria should first suggest renal calculus, but other causes, such as renal embolism, renal contusion, or laceration, must be considered.
- Is there dysuria or frequency of micturition associated with the hematuria? The presence of dysuria and frequency with the hematuria should suggest a bladder stone, prostatic disease, or a UTI.
- Is there fever? The presence of fever with the hematuria would suggest pyelonephritis.
- Is there a flank mass? The presence of bilateral flank masses with hematuria should suggest polycystic kidneys and hydronephrosis, whereas a unilateral flank mass would suggest a hypernephroma or unilateral hydronephrosis. A solitary cyst or renal vein thrombosis may also present with a flank mass and hematuria.
- Is there hypertension? The presence of hypertension with the hematuria suggests glomerulonephritis, polycystic kidneys, and collagen diseases.
- Are there other systemic signs and symptoms? If there are other systemic signs and symptoms, one should be looking for collagen disease, coagulation disorders, leukemia, and sickle cell anemia. When there is no hypertension or other signs and symptoms of systemic diseases, one should be looking for a benign or malignant tumor of the bladder, tuberculosis, or parasitic infection.
DIAGNOSTIC WORKUP
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
Hematuria:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
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)
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Source: In a Page: Signs and Symptoms, 2004
Hematuria:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
-
Transient (fever, dehydration, exercise)
-
Urinary tract infection
–Most common cause of gross hematuria
-
Hypercalciuria (common)
- Primary glomerulonephritis (GN)
–Acute poststreptococcal GN: Gross hematuria ±hypertension, oliguria; 5 days to several weeks after Group A strep pharyngitis or pyoderma; can also occur after other infections
–IgA nephropathy (Berger disease): recurrent gross hematuria occurs at or near onset of a URI
–Membranoproliferative GN
-
GN associated with systemic disease
–HSP
–SLE
–Other vasculitis (rare) e.g.,Wegener
-
Other glomerular disease
–Benign familial hematuria
–Alport syndrome: Usually X linked, high-
frequency deafness, progression to renal failure
–Glomerular disease (e.g., FSGS) usually presents as nephrotic syndrome
-
Tubulointerstitial disease
–Polycystic kidney disease, interstitial
nephritis, papillary necrosis, ATN
-
Urinary pelvic junction obstruction
-
Urolithiasis/nephrolithiasis
–Painless in up to 50% of children
-
Urethrorrhagia
–Recurrent gross hematuria (spotting on the
underwear)
–Most common in peripubertal males
-
Malignancies (e.g., Wilms tumor)
-
Vascular (e.g., renal vein thrombosis)
-
Trauma
-
Non-urinary tract blood
–Menses, perineal irritation, pinworms, masturbation, STDs, sexual abuse
-
Munchausen/Munchausen by proxy (rare)
Workup and Diagnosis
-
History
–Antecedent illness (including timing)
–Prior episodes, medication/food exposure
–Quality of gross hematuria (if present): Color, terminal vs present throughout stream, clots
–Symptoms: Fever, flank pain, dysuria, rash, hemoptysis, breathing difficulty, joint complaints
–Family history: Kidney stones, kidney disease, deafness (Alport)
-
Physical exam
–Blood pressure, growth parameters, skin or pharyngeal lesions, cardiac gallop, rales, edema, CVAT, genitourinary exam (external)
- Labs/studies
–U/A (dipstick and microscopy), urine culture
–Dipstick negative =foods, medications
–Dipstick positive, no RBCs =myoglobin, hemoglobin
–Dipstick positive, with RBCs =hematuria
–Macroscopic or microscopic with symptoms (e.g., HTN): Serum chemistries, CBC, ASO, C3, ANA, sickle prep, spot urine calcium/creatinine, STD screen (if sexually active), renal/bladder ultrasound, consider noncontrast helical CT if kidney stones suspected
–Microscopic hematuria, no symptoms: Repeat U/A two times, 1 week apart; if persists, check serum chemistries, urine culture, sickle prep, spot urine calcium/creatinine and U/As of parents/siblings
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Source: In A Page: Pediatric Signs and Symptoms, 2007
HEMATURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical picture will point to the diagnosis in many cases. If there is a history of abdominal trauma, a contusion or laceration of the kidney or bladder should be suspected. Massive trauma anywhere prompts a tentative diagnosis of crush syndrome. Purpura or bleeding from other sites suggests a coagulation disorder. Severe colicky pain in the abdomen suggests kidney stone. A long history of hypertension tension suggests polycystic kidneys, renal artery stenosis, or glomerulonephritis. A history of fever and rheumatic valvular disease suggests SBE with renal embolism. Painless hematuria in an otherwise healthy looking adult suggests neoplasm, whereas painful hematuria with frequency and dysuria suggests cystitis. Hematuria and a flank mass would make a neoplasm or polycystic kidney likely.
The initial workup should include a CBC, urinalysis, urine culture, chemistry panel, flat plate of the abdomen to assess the presence of stones and kidney size, and personal examination of the urinary sediment. If a renal calculus is suspected, an IVP is ordered immediately and a urologist consulted. A three-glass test will help localized the site of the bleeding. If there is blood in the initial specimen only, the urethra is probably the site of bleeding. If the blood is primarily in the final specimen, the bladder is most likely the site of bleeding. Equal blood discoloration in all specimens points to a renal lesion.
If renal tuberculosis is suspected an AFB smear and culture is done. If collagen disease is suspected an ANA analysis and anti–double strand DNA antibody titer is ordered. If a renal carcinoma is suspected, a CT scan of the abdomen is probably the best study to order but the advice of the urologist ought to be sought. Ultrasonography is useful in differentiating cysts from tumors. If a bladder neoplasm is suspected, cystoscopy will be done. If renal artery embolism or thrombosis is suspected, renal angiography may need to be done to clearly make the diagnosis.
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Source: Differential Diagnosis in Primary Care, 2007
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
Acute pyelonephritis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Diagnosis requires urinalysis and culture. Typical findings include:
❑ Pyuria (pus in urine): Urine sediment reveals the presence of leukocytes singly, in clumps, and in casts; and, possibly, a few red blood cells.
❑ Significant bacteriuria: Urine culture reveals more than 100,000 organisms/µl of urine.
❑ Low specific gravity and osmolality: These findings result from a temporarily decreased ability to concentrate urine.
❑ Slightly alkaline urine pH.
❑ Proteinuria, glycosuria, and ketonuria: These conditions are less common.
Excretory urography or computed tomography (CT) scan of the kidneys, ureters, and bladder also help in the evaluation of acute pyelonephritis by revealing calculi, tumors, or cysts in the kidneys and the urinary tract. In addition, excretory urography may show asymmetrical kidneys.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Kidney cancer:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Studies to identify kidney cancer usually include computed tomography scans, excretory urography, retrograde pyelography, ultrasound, cystoscopy (to rule out associated bladder cancer), and nephrotomography or renal angiography to distinguish a kidney cyst from a tumor.
Related tests include liver function studies showing increased levels of alkaline phosphatase, bilirubin, alanine aminotransferase and aspartate aminotransferase, and prolonged prothrombin time. Such results may point to liver metastasis, but if metastasis hasn't occurred, these abnormalities reverse after tumor resection.
Routine laboratory findings of hematuria, anemia (unrelated to blood loss), polycythemia, hypercalcemia, and increased erythrocyte sedimentation rate call for more testing to rule out kidney cancer.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Medullary sponge kidney:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Excretory urography is usually the key to diagnosis, often showing a characteristic flowerlike appearance of the pyramidal cavities when they fill with contrast material. It may also show renal calculi. Urinalysis is generally normal unless complications develop; however, it may show a slight reduction in concentrating ability or hypercalciuria. Diagnosis must distinguish medullary sponge kidney from renal tuberculosis, renal tubular acidosis, and papillary necrosis.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Polycystic kidney disease:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
A family history and a physical examination revealing large bilateral, irregular masses in the flanks strongly suggest polycystic kidney disease. In advanced stages, grossly enlarged and palpable kidneys make the diagnosis obvious. In patients with these findings, the following laboratory results are typical:
❑ Excretory urography reveals enlarged kidneys, with elongation of pelvis, flattening of the calyces, and indentations caused by cysts. Excretory urography of the neonate shows poor excretion of contrast medium.
❑ Ultrasound and computed tomography scan show kidney enlargement and the presence of cysts; tomography demonstrates multiple areas of cystic damage. Ultrasonography is the preferred imaging technique because it’s less expensive, doesn’t require contrast or radiation exposure, and is easily and safely performed on children and pregnant females.
❑ Urinalysis and creatinine clearance tests are nonspecific tests that evaluate renal function and reveal urine protein or blood in the urine.
Diagnosis must rule out the presence of renal tumors.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
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
Hematuria:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A thorough history is of utmost importance!
A. General aspects
1. Type of hematuria (macro/gross or microscopic).
2. Relationship to urination or timing of hematuria. The three-container method will help to separate the micturition into three portions with an initial, middle, and final portion.
Predominantly, initial hematuria results from anterior urethral disease; final hematuria results from disease of the bladder neck or posterior urethra; and hematuria throughout the stream suggests a disease site higher in the bladder, ureter, or kidney.
3. Urine color. Color can be affected by the following: Phenazopyridine (orange); nitrofurantoin (brown); rifampin (yellow-orange); l-dopa, methyldopa, and metronidazole (reddish-brown); phenolphthalein in laxatives, red beet and rhubarb consumption, food coloring, and vegetable dyes (red).
4. Clots, especially wormlike clots, suggest a location above the bladder neck.
5. Associated symptoms (e.g., recent sore throat, fever, chills, and flulike symptoms) may be the first sign of IgA nephropathy or postinfectious glomerulonephritis. Urinary frequency, dysuria, fever, chills, and urgency point to an infectious process. Diminished urine flow and abdominal pain or flank pain radiating into the groin can indicate the presence of urinary tract obstruction (Chapter 10.5). Vaginal discharge or bowel movement changes may hint at a nonurinary tract cause such as a foreign body (especially in children). A rash, joint pain, photosensitivity, flulike symptoms, and Raynaud’s phenomenon point to a collagen vascular disease.
B. Past medical history should lead to a suspicion of parasites (e.g., Schistosoma heamatobium) if the patient has traveled to endemic areas; of bladder tumor if there was exposure to chemical carcinogens (e.g., aniline dyes), or tobacco smoke. Other causes of hematuria detected in the history include drug ingestion and anticoagulation, and medical problems such as prostatic hypertrophy, diabetes mellitus (nephrosclerosis), analgesic medication abuse (renal papillary necrosis), nephrolithiasis, trauma (including vigorous masturbation), chemotherapy exposure with cyclophosphamide (chemical cystitis), antibiotic use (interstitial nephritis), previous urinary tract malignancies suggesting recurrence, and sickle cell disease (papillary necrosis).
C. Family history. Delineate any family history of polycystic kidney disease, sickle cell trait and disease, nephrolithiasis, various glomerular diseases, tuberculosis, and benign familial hematuria. The combination of renal failure, deafness, and hematuria suggests Alport’s hereditary nephritis.
Physical examination
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.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Hematuria:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ 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.
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Source: Field Guide to Bedside Diagnosis, 2007
Pyelonephritis, acute:
Diagnosis
(Handbook of Diseases)
Diagnosis requires urinalysis and culture. Typical findings include:
❑ pyuria (pus in urine) — urine sediment reveals the presence of leukocytes singly, in clumps, and in casts; and, possibly, a few red blood cells
❑ significant bacteriuria — more than 100,000 organisms/µl of urine revealed in urine culture
❑ low specific gravity and osmolality, resulting from a temporarily decreased ability to concentrate urine
❑ slightly alkaline urine pH
❑ proteinuria, glycosuria, and keto-nuria — less common.
X-rays also help in the evaluation of acute pyelonephritis. X-ray films of the kidneys, ureters, and bladder may reveal calculi, tumors, or cysts in the kidneys and urinary tract. Excretory urography may show asymmetrical kidneys.
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Source: Handbook of Diseases, 2003
Kidney cancer:
Diagnosis
(Handbook of Diseases)
Studies to identify kidney cancer usually include computed tomography scans, excretory urography and retrograde pyelography, ultrasound, cystoscopy (to rule out associated bladder cancer), and nephrotomography or renal angiography to distinguish a kidney cyst from a tumor.
Related tests include liver function studies showing increased levels of alkaline phosphatase, bilirubin, alanine aminotransferase, and aspartate aminotransferase as well as prolonged prothrombin time. Such results may point to liver metastasis, but if metastasis hasn’t occurred, these abnormalities reverse after the tumor has been resected.
Routine laboratory findings of hematuria, anemia (unrelated to blood loss), polycythemia, hypercalcemia, and increased erythrocyte sedimentation rate call for more testing to rule out kidney cancer. A bone scan should also be performed to rule out skeletal metastasis.
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Source: Handbook of Diseases, 2003
Polycystic kidney disease:
Diagnosis
(Handbook of Diseases)
A family history and a physical examination revealing large bilateral, irregular masses in the flanks strongly suggest polycystic kidney disease. In advanced stages, grossly enlarged and palpable kidneys make the diagnosis obvious. (See Visualizing the polycystic kidney.) In patients with these findings, the following laboratory results are typical:
❑ Excretory urography or retrograde ureteropyelography reveals enlarged kidneys, with elongation of the renal pelvis, flattening of the calyces, and indentations caused by cysts. Excretory urography of the neonate shows poor excretion of contrast medium.
❑ Ultrasonography, tomography, and radioisotope scans show kidney enlargement and cysts. Computed tomography scan and magnetic resonance imaging show multiple areas of cystic damage.
❑ Urinalysis and creatinine clearance tests (nonspecific tests that evaluate renal function) indicate abnormalities.
CLINICAL TIP: Diagnosis must rule out the presence of renal tumors.
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Source: Handbook of Diseases, 2003
Hematuria:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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 artifactitious hematuria, ask about bleeding hemorrhoids or the onset of menses, if appropriate. Ask if there’s any pain or burning with 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 any anticoagulants or aspirin.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Hematuria:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Hematuria without Proteinuria
Glomerular Disorders
Acute Postinfectious Glomerulonephritis
Usuallypresents within 1–2 wks after streptococcal pharyngitisor skin infection.Rare before 3 yrs of age.Disease spectrum varies from asymptomaticmicroscopic hematuria with normal renal function to acute renalfailure.Clinical manifestations include fever,abdominal or flank pain, edema, hypertension, and oliguria. Urinecolor is often reddish brown, and red cell casts are usually seen.Proteinuria may or may not occur. In almost all cases, C3 levelis decreased. Supporting evidence of preceding streptococcal infectioncan include positive throat culture, positive streptozyme, or elevatedantistreptolysin O titer.C3 level should return to normal withinabout 8 wks after onset of illness. Proteinuria can last for 6 mosand microscopic hematuria for 1–2 yrs, but virtually allchildren recover. Immunoglobulin A Nephropathy
Also knownas Berger disease.Can occur at any age, but peak incidenceis in adolescence and young adulthood.Usually presents with recurrent attacksof gross hematuria, which may be associated with upper respiratorytract infections.Microscopic hematuria can occur betweenepisodes of gross hematuria. Mild proteinuria also may occur, particularlyearly in the course. Renal function tends to be normal. Hypertension,nephrotic syndrome, and rapidly progressive course are unusual findings.Serum concentration of C3 is normal,and this helps to distinguish this disorder from acute postinfectiousglomerulonephritis. Immunoglobulin A is major immunoglobulin inmesangial deposits on renal biopsy. Henoch-Schönlein Nephritis
Common causeof vasculitis in childhood.Clinical features include abdominalpain, purpura on buttocks and lower legs, transient arthritis/arthralgiaof large joints, microscopic hematuria, and gastrointestinal bleeding.Diagnosis is usually clinical.Renal biopsy is indistinguishable fromimmunoglobulin A nephropathy.Some children develop chronic nephropathywith progression to end-stage renal disease. Alport Syndrome
Primaryfeature is recurrent gross hematuria or asymptomatic microscopichematuria. A number of affected children also have sensorineuralhearing loss. Later in life, individuals develop progressive renalinsufficiency.Usual form of genetic transmissionis X-linked, although autosomal-dominant and autosomal-recessiveforms occur. X-linked phenotype is due to mutation in the gene foralpha-5 chain of basement membrane collagen. Membranoproliferative Glomerulonephritis
Most commonin the second decade of life. 3 histologic types (I, II, III) havebeen described.Presentation is variable: gross ormicroscopic hematuria with or without proteinuria or nephrotic syndrome.Hypertension is common, and renal function may be decreased.Serum C3 level is usually low. C3 nephriticfactor may be present, especially in type II. Different types canonly be distinguished by renal biopsy. Systemic Lupus Erythematosus
Chronicmultisystem autoimmune disease that is most common in adolescent girls.Characteristic findings include fever,arthritis, weight loss, and nephritis. Hematuria and proteinuriaare common urinary findings. Antinuclear antibody is usually positiveand serum C3 is usually low.Antibody to double-stranded DNA isdiagnostic. Renal biopsy usually shows proliferative glomerulonephritiswith immunoglobulin G and C3 deposits. Familial Benign Hematuria (Thin Basement Membrane Nephropathy)
Autosomal-dominantdisorder in which hematuria is usually microscopic. Positive familyhistory of hematuria and absence of proteinuria suggest diagnosis.Electron microscopy shows thinning of glomerular capillary basementmembrane.Although thought to be benign, reportby Dische et al. (1985) described thin basement membrane nephropathyin several individuals who developed progressive renal disease.Further study is required to determine whether this disorder isreally benign. Nonfamilial Benign Hematuria
In many children, diagnostic studies do notreveal the cause of hematuria. These children are categorized ashaving benign nonfamilial hematuria. After months or years, hematuriafrequently disappears. Although this disorder is often benign, somechildren may have slowly developing glomerulonephritis. As longas hematuria exists, these patients should be tested at 6-mo intervalsto determine whether proteinuria develops.
Nonglomerular Disorders
Urinary Tract Infection
Common symptomsare dysuria, frequency, urgency, fever, abdominal pain, flank pain,and vomiting. Microscopic or gross hematuria can occur along withpyuria and bacteriuria.Positive urine culture confirms thediagnosis.See Chap.15, Dysuria. Trauma
Blunt orpenetrating injury to kidney or any portion of urinary tract cancause gross or microscopic hematuria.With minor trauma and microscopic hematuriain asymptomatic individuals, renal U/S should be performedto search for anatomic abnormality (e.g., hydronephrosis or renalcyst) because minimal trauma rarely causes hematuria in normal kidneys.Otherwise, CT is radiologic study of choice.Urethral trauma may occur followingcrush-type injury from fractured pelvis or direct injury, and urethrographymay be diagnostic. Exercise
Vigorous exercise can produce gross or microscopichematuria, which usually resolves within 1–2 days.
Hydronephrosis
In children with hydronephrosis, microscopicor gross hematuria may occur following mild flank or abdominal trauma.Renal U/S may be performed initially.
Renal Vein Thrombosis
Predisposingfactors include perinatal asphyxia, dehydration, septicemia, shock,and coagulopathies (e.g., protein C deficiency).Gross hematuria usually occurs alongwith palpable unilateral or bilateral flank masses.Renal U/S with Doppler methodsis diagnostic. Hemoglobinopathies
HemoglobinopathiesSA, SC, SS, CC, AC, and sickle beta-thalassemia can produce renalbleeding and microscopic or gross hematuria.Hemoglobin electrophoresis is diagnosticand should be performed in any African-American child with hematuriaof unknown cause. Idiopathic Hypercalciuria
Microscopicor gross hematuria may occur with increased urinary calcium excretion withoutevidence of urinary stone disease. However, hypercalciuria is riskfactor for development of urolithiasis.Urine calcium:creatinine ratio (mg:mg)of greater than normal for age can screen for this disorder (Matoset al., 1997). If spot ratio is greater than normal, 24-hr urinecalcium excretion should be measured. Calcium excretion of >4mg/kg/day is indicative of hypercalciuria. Urolithiasis
Causes inchildren include urinary tract infection, hypercalciuria, hyperuricosuria, cystinuria,and primary hyperoxaluria.When urinary stone is being passed,abdominal or flank pain (renal colic) and microscopic or gross hematuriaare usual findings.Diagnostic investigations should includeUA; urine culture; blood urea nitrogen; and serum measurements ofcalcium, phosphorus, uric acid, and creatinine.CT is recommended to search for underlyingdisease and localize any obstruction.When calculi are recovered from urine,their biochemical contents should be analyzed. If they are unrecoverablefrom urinary tract, determination of calcium:creatinine ratio inrandom urine specimen should be performed. Ratio greater than normalfor age can screen for hypercalciuria. More precise test is measurementof 24-hr urine calcium excretion.If these tests are negative, 24-hrurinary excretion of cystine, oxalate, and uric acid should be performed. Polycystic Kidney Disease
Autosomal-Recessive
Gene hasbeen mapped to chromosome 6.Common findings in neonates are grossor microscopic hematuria, bilateral flank masses, hypertension,and azotemia.Renal U/S usually revealslarge echogenic kidneys. Cysts are microscopic and not seen by imaging.Liver disease is congenital hepaticfibrosis.Diagnosis is usually clinical and radiologic. Autosomal-Dominant
Rarely encounteredin childhood.At least 3 different genetic mutationshave been found.Gross or microscopic hematuria, unilateralor bilateral abdominal masses, and hypertension are common findings.Abdominal U/S shows enlargedpolycystic kidneys and hepatic cysts.Diagnosis is usually based on clinicaland radiographic findings. Renal Tuberculosis
Usuallydoes not occur until primary disease has been established over several years.Usually associated with tuberculouscystitis, which can produce suprapubic pain and dysuria.Gross or microscopic hematuria andpyuria are characteristic.Mantoux test is usually positive.Usual urine culture for bacteria isnegative, whereas urine culture positive for acid-fast organismsis diagnostic. Vascular Malformations
Arteriovenousmalformations of kidney can present with gross hematuria.Renal U/S and CT may locatemalformation. Renal angiography is definitive. Foreign Body in Urethra or Bladder
Foreignbody in urethra or bladder usually produces urethral or suprapubicpain, dysuria, and hematuria.Abdominal radiography may reveal radiopaqueforeign body. Cystoscopy can confirm diagnosis.It is important to note that a foreignbody in the vagina can produce bleeding that may be mistaken forhematuria. Neoplasm
A numberof genitourinary neoplasms occur in the pediatric population.Wilms tumor, most common renal tumorin children, usually presents as abdominal or flank mass that doesnot cross midline unless it is very large. Gross hematuria occursin small number of cases. Renal U/S or CT shows renal massthat distorts collecting system.Renal hemangioma is rare lesion thatcan present with recurrent gross hematuria. Diagnosis is confirmedby renal angiography.Renal carcinoma is rare in pediatricpopulation, but renal U/S can demonstrate mass lesion.Bladder tumors are exceedingly rarein children, but suprapubic mass is sometimes palpable. Most commonbladder tumor is rhabdomyosarcoma, which can present with hematuriaor acute urinary retention. Abdominal U/S, CT, and cystoscopyare useful in locating and defining extent of tumor.In all cases of genitourinary tractneoplasms, histologic diagnosis is definitive. Bleeding Disorders
Although gross or microscopic hematuria mayoccur with bleeding disorders (hemophilias, thrombocytopenia, disseminatedintravascular coagulation), it is uncommon to have isolated hematuriaas only manifestation. See Chap.53, Recurrent Infection.
Drugs
A number of drugs (penicillins, sulfonamides,cephalosporins, rifampin, tetracycline, cisplatin, lithium) maycause gross or microscopic hematuria. Cyclophosphamide may causehemorrhagic cystitis.
Hematuria with Proteinuria
Hematuriawith proteinuria may occur with several glomerular renal disordersas discussed previously:Acute postinfectious glomerulonephritisImmunoglobulin A nephropathyHenoch-Schönlein nephritisAlport syndromeMembranoproliferative glomerulonephritisSystemic lupus erythematosus Other glomerular renal diseases thatusually present with hematuria and proteinuria are discussed inthis section. Membranous Nephropathy
Most commonduring second decade of life and usually presents with nephroticsyndrome. Microscopic hematuria is more common than gross hematuria.Renal biopsy confirms diagnosis. Glomerulonephritis of Chronic Infection
Disordersassociated with glomerulonephritis of chronic infection includeendocarditis and ventriculoatrial shunt infections.Clinical features are those of acuteglomerulonephritis, namely edema, hypertension, and renal insufficiency.Serum C3 is often decreased. Idiopathic Rapidly Progressive Glomerulonephritis
Uncommondisease in children; often preceded by viral illness.Affected children have acute onsetof hematuria, proteinuria, oliguria or anuria, and azotemia.Serum C3 level is normal or mildlydecreased. Many children progress to end-stage renal disease withina few weeks or months without treatment.Renal biopsy and clinical course arediagnostic. Hemolytic-Uremic Syndrome
Typicalform follows prodromal illness consisting of fever, vomiting, abdominal pain,and, often, bloody diarrhea. This is followed in 5–10 daysby hemolytic anemia with fragmented red cells, thrombocytopenia,and acute renal injury with hematuria, proteinuria, and often oliguriaor anuria.Most common pathogen is E. coli 0157:H7. Polyarteritis Nodosa
Necrotizingvasculitis that affects small and medium-sized arteries. Althoughcause is unknown, it may follow viral URI, streptococcal infection,or chronic hepatitis B infection.Characteristic findings include fever,abdominal pain, hematuria, hypertension, purpura, arthritis, andstroke.Lab findings include increased sedimentationrate, anemia, leukocytosis, proteinuria, and hypergammaglobulinemia.In some cases, antineutrophil cytoplasmic antibody is found.Biopsy demonstrating the vasculitisis diagnostic. Antiglomerular Basement Membrane Disease (Goodpasture Disease)
Associationof pulmonary hemorrhage and glomerulonephritis in which antibodies againstlung and glomerular basement membrane can be demonstrated.Characteristic findings are hematuria,proteinuria, hemoptysis, and progressive renal failure. Serum C3level is normal.Renal biopsy shows linear stainingof immunoglobulin G along glomerular basement membrane. Focal Segmental Glomerulosclerosis
Clinicallyindistinguishable from minimal change nephrotic syndrome but shouldbe suspected when there has been inadequate response to standardcorticosteroid therapy.Microscopic hematuria and occasionallygross hematuria may occur.Renal biopsy is diagnostic. Wegener Granulomatosis
Disorderof unknown cause characterized by vasculitis that affects upperand lower respiratory tract and kidneys.Fever, malaise, weight loss, hemoptysis,dyspnea, hematuria, and proteinuria are characteristic findings.Antineutrophil circulating antibodiesthat bind to proteinase 3 are specific for this disorder. Sinus,airway, lung, or kidney biopsy that shows necrotizing granulomatouslesions and presence of specific antineutrophil circulating antibodiesthat bind to proteinase 3 confirm the diagnosis. Diagnostic Approach
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.
» READ BOOK EXCERPT ONLINE »
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.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
HEMATURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical picture will point to the diagnosis in many cases. If
there is a history of abdominal trauma, a contusion or laceration of the
kidney or bladder should be suspected. Massive trauma anywhere prompts a
tentative diagnosis of crush syndrome. Purpura or bleeding from other sites
suggests a coagulation disorder. Severe colicky pain in the abdomen suggests
kidney stone. A long history of hypertension suggests polycystic kidneys, renal
artery stenosis, or glomerulonephritis. A history of fever and rheumatic
valvular disease suggests SBE with renal embolism. Painless hematuria in an
otherwise healthy looking adult suggests neoplasm, whereas painful hematuria
with frequency and dysuria suggests cystitis. Hematuria and a flank mass
would make a neoplasm or polycystic kidney likely.
The initial workup should include a CBC, urinalysis, urine culture,
chemistry panel, flat plate of the abdomen to assess the presence of stones
and kidney size, and personal examination of the urinary sediment. If a
renal calculus is suspected, an IVP is ordered immediately and a urologist
consulted. A three-glass test will help to localize the site of the
bleeding. If there is blood in the initial specimen only, the urethra is
probably the site of bleeding. If the blood is primarily in the final
specimen, the bladder is most likely the site of bleeding. Equal blood
discoloration in all specimens points to a renal lesion.
If renal TB is suspected, an acid-fast bacillus (AFB) smear and culture is
done. If collagen disease is suspected, an ANA analysis and
anti–double-strand DNA antibody titer is ordered.
If a renal carcinoma is suspected, a CT scan of the abdomen is probably the
best study to order, but the advice of a urologist ought to be sought.
Ultrasonography is useful in differentiating cysts from tumors. If a bladder
neoplasm is suspected, cystoscopy will be done. If renal artery embolism or
thrombosis is suspected, renal angiography may need to be done to clearly
make the diagnosis.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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