HEMATURIA DAVID SPELLBERG M.D.,FACS NAPLES UROLOGY ASSOCIATES

MICROSCOPIC versus GROSS HEMATURIA Microscopic hematuria is seen only under a microsope, whereas Gross hematuria is visible to the naked eye.

25% of patients with gross hematuria have a life threatening urologic lesion 5 to 20% of patients with microscopic hematuria may have a serious urologic disorder 1% of patients may develop a neoplasm even though an initial workup is negative within 3-4 years Up to 18% of normal individuals may have some degree of microscopic hematuria

MICROSCOPIC HEMATURIA DEFINITION: 3 or more RBC’S per HPF on a microscopic evaluation from a minimum of 2 PROPERLY collected urine specimens. (AUA BEST PRACTICE POLICY PANEL 2001).

DETECTION OF HEMATURIA Dipstick testing 91% sensitivity, 65% specificity for the detection of Hgb False positives caused by: –Myoglobinuria –Menstrual bleeding –Dehydration (increased SG level) –Outdated or dried dipsticks –Substances or medications

Substances and medications Artificial food coloring Beets Berries Lead or mercury poisoning Meds: adriamycin, chloroquine, hydroxychloroquine, metronidazole, nitrofurantoin, phenazapyridine, rifampin

Most common causes S stones I infection T tumor T trauma

Etiology of Hematuria V vascular I infectious T Tumor/ trauma A anatomic anomaly M metabolic I inherited N nonspecific

Vascular Aneursym Renal vein thrombosis/ Infarct Malignant hypertension nephritis

Infectious Bacterial (remember levaquin) Viral Fungal Parasitic TB

Tumor/ trauma Kidney, ureteral, bladder, prostate, urethral malignancy Instrumentation Radiation Exercise Foreign body Trauma

Anatomic anomaly BPH benign prostatic hyperplasia Pelvic muscle relaxation Renal duplication UPJ obstruction Polycystic kidney Medullary sponge kidney Strictures Ureterocele or urethrocele

Metabolic Kidney stones Bladder stones Drug induced

Inherited IgA nephropathy (Berger’s disease) Sickle cell anemia Benign familial hematuria

Nonspecific Physiologic –Exercise –Fever False Positive -Endometriosis -Vaginal bleeding -factitious

History Gross vs. microscopic Initial, terminal, or throughout stream Painful, irritation, or flank pain Recent strep or skin infection Medications Smoking, occupational exposure Trauma/ instrumentation, radiation/ chemo

Physical exam Vital signs Rashes, petechiae, mottling Flank or abdominal mass Genitalia exam

Lab studies UA UA C&S BMP If indicated: CBC, PT/PTT/ INR IVP, CT urogram, Renal ultrasound, retrograde pyelograms

Urology referral If not previously evaluated for hematuria, ALL patients need a cystoscopic examination of the bladder mucosa. NO radiologic study or urinary test (cytology, NMP-22, or BTA-stat) fully evaluates the bladder.

Nephrology referral Significant proteinuria without hematuria RBC casts Elevated creatinine above 2.5

Follow up Somewhat controversial Repeat UA, cytology every 6 months for 2 years followed by yearly exams. Re-evaluation for a new episode of gross hematuria if over 6 months and no previous cause was found. 18% of patients may always have hematuria without a definitive cause