Hematuria Flashcards
(26 cards)
Microscopic hematuria
- “Microhematuria”
- >3 RBCs per HPF on microscopy w/ centrifuged sample
- Any single urinalysis w/ >3 RBC/hpf must be evaluated
- Urine dipstick is not sufficient to diagnose microscopic hematuria
- 4% of pts w/ microscopic hematuria will be found to have urologic malignancy
*follow-up eval will reveal malignancy in up to 3% of initially neg. pts.
Gross/Macroscopic hematuria
- Visible blood in the urine
- Any episode of grossly visible blood in the urine must be evaluated
- “Macrohematuria”
- 23% of pts w/ gross hematuria may be found to have a urologic malignancy
*follow-up eval will reveal malignancy in up to 18% of initially neg. pts.
Causes of false positive dipstick
- Myoglobinuria
- 1-2 RBC/hpf
- Low urine specific gravity causing RBC lysis
- Hemoglobinuria
Causes of false negative dipstick
- High vit. C intake
- Acidic urine
- Concentrated urine
- Proteinuria
Macrohematuria masqueraders
- Drugs
*phenazopyridine (pyridium)
*rifampin
- Myoglobinuria
- Bilirubinuria
- Porphyria
- Menses/vaginal bleeding
- Concentrated urine
- Beets/rhubarb
Sources of hematuria
- Nephrologic
*glomerulous
*nephron
- Urologic
*collecting system
*ureter
*bladder
*prostate
*urethra
Nephrologic/Renal hematuria presentation
- Typically microscopic hematuria
Red blood cell casts on microscopy
- Always pathologic
- Many conditions
*glomerulonephritis
*lupus
*goodpasture’s syndrome
*any renal injury/insult/infarction
Initial hematuria
- The initial stream results in visible blood that transitions to clear urine
- Most commonly urethral source
*stricture
*urethritis
*malignancy (rare)
Terminal hematuria
- The initial stream is clear urine that transitions into visible blood
- bladder trigone
- Bladder neck
*irritated w/ voiding
- Prostate
*BPH
*prostate cancer
Total hematuria
- The entire stream contains visible blood
- Bladder, ureter, renal pelvis
*tumor
*hemorrhagic cystitis
- Prostate
*BPH
*prostate cancer
Upper GU tract organs
- Kidney
- Renal pelvis
- Ureters
Lower GU tract organs
- Bladder
- Prostate
- Urethra
Gold standard of imaging hematuria patients
- CT urogram
CT Urogram
- CT w/ and w/o IV contrast, w/ delayed imaging opacifying the renal pellvis, ureters and bladder
- Obviates the neeed for retrograde pyelograms
- Gold standard test
- Avoid in renal pts due to IV contrast
Renal/Bladder Ultrasound
- May not differentiate less obvious renal lesion
- Requires retrograde pyelograms to complete workup
Workup of hematuria patient
- History and physical
*DRE in males
*bimanual exam in females
- Urinalysis/Urine culture
*pos. dipstick must be ruled out w/ 3 additional microscopic urinalyses
- Urine cytology
*symptomatic microhematuria, persistent microhematuria, gross hematuria
- Lab eval
*CBC; hemoglobin, WBC, platelet count
- Coags
*PT, PTT, INR
- Chemistry
*creatinine
*BUN
- PSA
*in the appropriate pt.
Cystoscopy evaluation required for
- Gross hematuria
- Microscopic hematuria >35
- Microscopic hematuria <35 if risk factors or persistent
Ureteroscopy evaluation required for
- If blood seen emanating from ureteral orifice on cystoscopy or pos. cytology w/ neg. cystoscopy, or pos. CTUrogram/retrograde pyelograms
- Selective cytology
Prostatic hematuria treatment
- Endoscopic resection (TURP)
- 5alpha-reductase inhibitors
Hemorrhagic cystitis
- Diffuse inflammation and bleeding from bladder mucosa
- Infectious causes
*BK virus in immunocompromised
*adenovirus
- Post radiation
- Chemical
- Cyclophosphamide (prevent w/ mesna)
- Numerous others, less common
Refractory hemorrhagic cystitis treatment
- Hyperbaric oxygen therapy
- Aminocaproic acid
- Formalin
- 1% Alum
Hyperbaric oxygen therapy
- Used to treat recurrent hemorrhagic cystitis
- Enhanced angiogenesis, vasoconstriction, immune function
Aminocaproic acid
- Used to treat recurrent hemorrhagic cystitis
- Inhibits plasmin/clot lysis
- IV, PO, or intravesical
- Prothrombotic
