1. DIAGNOSIS AND TREATMENT OF HEMATURIA
Rainy Umbas
Department of Urology
“Cipto Mangunkusumo” Hospital / Faculty of Medicine
University of Indonesia

2. What is hematuria?
What causes hematuria?
Is hematuria always a bad thing?
What tests are needed?
What is the treatment?
What if no cause is found?

3. What is hematuria?
Hematuria means the appearance of blood in the urine.
It could be visible (= macroscopic hematuria)
Or microscopic hematuria, it means there were three or more red blood cells per high-power microscopic field in urinary sediment

4. (McDonald MM et al, Am Fam Physician 2006)
What causes hematuria?
Macroscopic hematuria : about one in three cases are associated with malignancy somewhere in the urinary tract (
Microscopic hematuria : maybe associated with urologic malignancy in up to 10% of adults
(Khadra MH et al, J Urol 2000; 163: )
Glomerular cause
Non-glomerular cause: - renal
- extra-renal
- other causes
(McDonald MM et al, Am Fam Physician 2006)

5. What causes hematuria? Glomerular cause: Alport’ syndrome
Membranoprliverative glomerulonephritis
Fabry’s disease
Mesangial proliverative glomerulonephritis
Goodpasture’s syndrome
Nail-patella syndrome
Hemolytic uremia
Other postinfectious glomerulonephritis
Henoch-Schönlein purpura
Thin basement nephropathy (benign familial hematuria)
Immunoglobulin A nephropathy
Wegener’s granulomatosis
Lupus nephritis
Poststreptococcal glomerulonephritis
(McDonald MM et al, Am Fam Physician 2006)

6. Medications that can cause hematuria:
What causes hematuria?
Medications that can cause hematuria:
Aminoglycosides
Cyclophosphamide (Cytoxan)
Amitriptyline
Diuretics
Analgesics
Oral contraseptives
Anticonvulsants
Penicillins (extended spectrum)
Aspirin
Quinine
Busulfan
Vincristine (Oncovin)
Chlorpromazine
Warfarin (Coumadin)
(McDonald MM et al, Am Fam Physician 2006)

7. Non-glomerular cause:
What causes hematuria?
Non-glomerular cause:
Renal (tubulointerstitial)
Acute tubular necrosis
Familial
- hereditary nephritis
- medullary cystic disease
- multicystic kidney disease
- polycystic kidney disease
Infection: pyelonephritis, tuberculosis, schistomiasis
(McDonald MM et al, Am Fam Physician 2006)

8. What causes hematuria? Non-glomerular cause Renal (con’t):
Interstitial nephritis
- drug induced
- infection: syphylis, toxoplasmosis, viral
- systemic disease: sarcoidosis, lymphoma
Loin pain-hematuria syndrome
Metabolic
- hypercalciuria
- hyperuricosuria
(McDonald MM et al, Am Fam Physician 2006)

9. What causes hematuria? Non-glomerular cause Renal (con’t):
Renal cell carcinoma
Solitary renal cyst
Vascular disease
- arteriovenous malformation
- malignant hypertension
- renal artery embolism/thrombosis
- renal venous thrombosis
- sicle cell disease
(McDonald MM et al, Am Fam Physician 2006)

10. What causes hematuria? BPH Non-glomerular cause Extra-renal: Calculi
Coagulopathy related: warfarin, heparin, secondary to systemic disease
Congenital abnormalities
Endometriosis
Factitious
Foreign bodies
Infection: prostate, epididymis, urethra, bladder
(McDonald MM et al, Am Fam Physician 2006)

11. Hematuria
Stone or BPH as a cause for hematuria

12. What causes hematuria? Non-glomerular cause Extra-renal (con’t):
Inflammation: drug or radiation induced
Perineal irritation
Posterior urethral valves
Strictures
TCC of ureter, bladder
Trauma: catheterization, blunt trauma
Tumor
(McDonald MM et al, Am Fam Physician 2006)

13. Hematuria
Malignancy of kidney/collecting system, ureter, bladder, prostate, and urethra

14. What causes hematuria? Non-glomerular cause Other causes:
Exercise hematuria
Myoglobinuria due to strenuous exercise, associated with muscle pain and tenderness
Menstrual contamination
Sexual intercourse

15. Hematuria
Strenuous exercise can cause blood in urine ! ! !

16. CLINICAL PICTURE OF HEMATURIA
Initial hematuria
Entirely hematuria (total)
Terminal hematuria
(Courtesy of Prof. Dr. Djoko Rahardjo)

17. THE SOURCE OF THE BLEEDING
Initial hematuria
possible source of bleeding :
Penile or bulbous urethra
The flow of urine initials bleed and afterwards “wash clear”
Pathology : inflammation, stone, malignancy
(Courtesy of Prof. Dr. Djoko Rahardjo)

18. THE SOURCE OF BLEEDING
Entirely Hematuria
Source : higher than bladder neck The blood mixed with urine, due to: © Malignancy © Stone © Infection including TB
(Courtesy of Prof. Dr. Djoko Rahardjo)

19. Bladder neck due to “snapping shut”
THE SOURCE OF BLEEDING
Terminal Hematuria
Prostatic urethra
Bladder neck due to “snapping shut”
(Courtesy of Prof. Dr. Djoko Rahardjo)

20. Is hematuria always a bad thing?
It may not be important if any of the following can explain it :
Hematuria during a menstrual period
When it occurs only during a urinary infection
Some medicines or foods can coor the urine red. This is not the same as passing blood
When it only occurs following strenuous exercise

21. What test are needed?
First of all is to prove that the red urine is hematuria: urine sediment or strip test

22. What tests are needed? Physical exam incl. blood pressure
Confirm with urine microscopic exam if striptest / dipstick was positive.
Strip test / dipstick cannot distinguish among myoglobin, hemoglobin, and red blood cells
Urine test:
- presence of infection
- proteinuria, red cell casts or dysmorphic red blood cells (together with increased creatinine) suggestive of glomerular cause referred to nephrologist

23. What tests are needed? Urine cytology
The sensitivity of urine cytology is highest for detection of high-grade lesions in the bladder and carcinoma in situ
Urine cytology studies alone may provide sufficient evaluation of the lower urinary tract in certain low-risk patients
Urine PCR for TB / acid-fast bacilli staining
Consider for referral to urologist for further evaluation

24. What tests are needed? Imaging: - Ultrasonography
- KUB & IVU or CT Scan

25. Should have their lower tract assessed by cystoscopy
What tests are needed?
Patients > 40 years old, those with posotive or atypical cytology, or any patient with the presence of any of the following risk factors:
- smoking history
- occupational exposure to chemicals or dyes
- history of irritative voiding symptoms
- analgesic abuse with phenacetin
- history of pelvic irradiation, or cyclophosphamide exposure
Should have their lower tract assessed by cystoscopy

26. What tests are needed?
Cystoscopy or Uretero-renoscopy

27. What is the treatment?
Hematuria has no specific treatment. One should focus on the underlying condition ! ! !
Underlying cause
Treatment
Urinary tract infection
Antibiotics
Kidney disease
Relieve inflamation and limit further damage
Inherited disorders
Vary greatly depend on the disorders
Stone disease
Stone removal
BPH
Relieve obstruction & irritation
Malignancy
Depend on tumor stage

28. What if no cause is found?
If there are no signs of serious disease, follow-up every 6 months, up to 36 months, of the urinalysis, urine cytology, blood test and blood pressure.
This is especially important for persons > 40 years old who have risk factors for urothelial cancers:
- smoking history
- occupational exposure to benzenes or aromatic amines (e.g. Leather dye, rubber, tire industries)
- or history of urologic neoplasm
This group of patients merit referral to a urologist for cystoscopy

29. What if no cause is found?
Immediate urologic re-evaluation with consideration of cystoscopy, cytology or repeat imaging should be performed in case of:
- gross hematuria
- abnormal urinary cytology
- irritative voiding symptoms without infection
If none of these occurs within three years, the patient does not require further urologic monitoring

30. Conclusions
Hematuria, especially microscopic, present a challenging clinical scenario for family physicians / general practioners
All patients should be investigated by urine cytology and urinary tract imaging after excluding non-important causes (menses, infection, exersice ect)
Referral to urologist for further evaluation and cystoscopy is indicated in patients with positive or atypical cytology, patients > 40 years old, and any patients risk factors
Patients with suspicious cause of glomerular cause should be referred to nephrologist
Patients shoulod be followed up to 3 years

31. References Mayo Clinic.com (www.mayoclinic.com)
Renal unit, Royal Infirmary of Edinburg (
Grossfeld GD et al, Am Fam Physician 2001; 63:
Khadra MH et al, J Urol 2000; 163:
McDonald MM et al, Am Fam Physician 2006; 73:
Wollin T et al, Can Urol Assoc J 2009; 3: 77-80

32. Acknowledgements Prof. Djoko Rahardjo, MD Chaidir A. Mochtar, MD, PhD
Rizal Hamid, MD
Mr. Ruhyat Yamani
Ms. Leslie Dolfo Nugroho
Ms. Tri Darani
Department of Urology
“Cipto Mangunkusumo” Hospital /
Faculty of Medicine, University of Indonesia