Approach to Hematuria zResident teaching rounds zSteve Radke :) zJuly 30, 2003 zReference: Cohen et al. NEJM 348;23 June 5, P

Hematuria zClinical case zClassification zDDx zHistory, Physical zInvestigations zApproach

Clinical Case z48 year old healthy female z5 rbc/hpf zDoctor….what’s going on?

Classification zGross hematuria zMicroscopic hematuria y>= 2 rbc/hpf zTrue zPseudohematuria xmenses xdyes beets, candy, juices xmeds (e.g.. rifampin) xmyoglobinuria, hemoglobinuria due to hemolysis

Classification zGlomerular zNonglomerular yupper urinary tract ylower urinary tract zDiagnostic

DDx (without the minutia) zOrigin 50 yo zGlomerularIgA nephropathy IgA nephropathy zNonglomerular z Upper tractnephrolithiasis nephrolithiasis y pyelonephritis renal-cell ca y polycystic kidney polycystic kidney yLower tract cystitis, prostatitis, urethritis y benign bladder tumors bladder ca y bladder ca prostate ca y prostate ca benign bladder y tumors

History zage ztiming zurinary sxs zSTI zflank pain ztrauma, exercise zobstructive sxs zRFs: smoking, chemicals, radiation

Physical exam zB.P. zabdominal exam zDRE

Investigations - glomerular zUrine dip yprotein, WBC, nitrites zUrine microscopy yrbc count ywbc count yred cell casts zIf Red Cell Casts, Protein or Increased Cr z ---> glomerular origin

Investigations - upper tract zU/S xlimited in detecting solid tumors <3cm yIVP xradiographic contrast die exposure xless sensitive and specific than U/S xsometimes can not differentiate solid vs cystic masses yCT xwith and w/o contrast xpreferred method

Investigations - lower tract zCystoscopy zUrine Cytology yless sensitive than cystoscopy, but ymore specific yAM void samples x 3

The Approach zMicroscopic hematuria zurine dipstick +ve z repeat urine dipstick -ve w/u ends unless z (several days later) RF for bladder ca z +ve zGross hematuria microscopy z red cell casts no red cell casts z z glomerular hematuria nonglomerular hematuria

The Approach z glomerular hematuria z NO protein or +ve protein or z renal insufficiency renal insufficiency z periodic medical follow-up Nephrology referral z monitor for proteinuria or for renal biopsy z renal insufficiency z (q 6-12 months)

The Approach z nonglomerular hematuria z CT +ve refer based z (or U/S) on lesion z -ve z urine cytology +ve cystoscopy z -ve z z >= 50 or <50 and z RF for bladder Ca or no RF for bladder Ca z gross hematuria z cystoscopy w/u ends (yearly urinalysis)

Take home messages z>50 yo R/o Ca zdo casts zCT (not u/s or ivp)