1. Hematuria Wanda C. Hancock, MHSA, PA-C

2. Objectives Discover the presenting symptoms for hematuria and the anticipated decision path for its etiology Develop an initial differential diagnosis for hematuria Consider the diagnostic orders for developing the diagnosis Determine the likely follow up testing.

3. Hematuria is a sign of malignancy until proven otherwise

4. Incidence 43% of microscopic hematuria has no etiology 5% of microscopic hematuria is cancer 23% of gross has cancer as an initial finding 8% has no etiology initially but 18% findings later

5. Causes Cancer BPH Trauma Surgery/instrumentation Medications Renal Disease Exercise Stones Radiation Chemotherapy Fever Benzenes UTI Recent URTI

6. Risk Factors Age Smoking Trauma Previous exposure to chemicals

7. How to Shine…. Gross or microscopic? Timing? Pain? Clots?

8. Gross VS Micro Gross hematuria Always needs evaluation Sources Microscopic Dip stick has 90% sensitivity 3-5 RBC HPF 2 of 3 tests positive

9. Timing …. Initiation of the stream Terminal hematuria Throughout the micturation

10. Painful versus painless Painful Cystitis Stones Painless Neoplasm

11. Clots? Amorphous Veriform

12. PeePee on T (4) his Period, pseudo hematuria Prostate Obstruction Nephritis Trauma Tumor TB Thrombosis Hematologic Infection/Inflammation Stone

13. Evaluation PMH FMH PE Laboratory Imaging

14. Past Medical History Radiation Surgery TB Autoimmune disease Exercise Trauma Recent URTI LUTS

15. Family History HTN PCKD Alport Syndrome Stones Cancer

16. Physical Examination Blood pressure Pallor Rashes Edema Murmur Palpable mass Flank pain DRE Pelvic

17. Laboratory tests Urine Dip Microscopic examination Culture Cytology Creatinine, BUN PT/INR Urovision Other ANA SCD TB

18. Imaging IVP or CT urogram Ultrasound MRI or CT Retrograde pyelogram Mag 3 / renal scan Cystogram

19. Differential Diagnosis Pseudohematuria Drugs, vegatables, dyes Myoglobin Menstration Dysfunctional bleeding Congenital Cystic renal disease Alports disease Renal tubual disorder

20. Differential Diagnosis Anatomic Strictures Phimosis Posterior urethral valves Diverticulum UPJ obstruction Vesicouretric reflux Vascular malformation Trauma Exercise induced Foreign body/inflammatory

21. Follow Up Negative CT, cytology, cystoscopy Clinic follow up should be scheduled 6, 12, 24, 36 months UA, BP, cytology Retesting Change of symptoms Gross hematuria develops

22. Resources Campbell-Walsh Urology, 9 th edition. Wein, Alan, et al. Saunders/Elsevier, Philadelphia, PA, 2007. Clinical Manual of Urology, 3 rd edition. Hanno, Phillip, Malkowicz, S. Bruce, Wein, Alan. McGraw-Hill, NY, NY, 2007. Office Urology: The Clinican’s Guide. Kursh, Elroy D., Ulchaker, James C.. Humana Press, Totowa, NJ, 2001. Pocket Guide to Urology, 3 rd edition. Wieder, Jeff A.. Griffith Publishing, Caldwell, ID, 2007. Smith’s General Urology, 17 th edition.Tanngho, Emil A., McAninch, Jack W.. McGraw-Hill/Lange, NY, NY, 2008. The 5-Minute Urologic Consult, 2 nd edition. Gomella, Leonard G. Lippincott Williams & Wilkins, Philadelphia, PA, 2010. Urology House Officer Series, 4 th edition. Macfarlane, Michael T. Lippincott Williams & Wilkins, Philadelphia, PA, 2006.