Download Hematuria in Primary Care: The Bloody Truth

Hematuria in Primary
Care: The Bloody Truth
Ashlyn Bruning, MMS, PA-C
NCAPA Summer Conference
Disclosure:
I Have No Financial or Non-financial Relationships or Conflicts of Interest to
Disclose
OBJECTIVES
 1. Define Hematuria
 2. Differentiate dipstick positive hematuria vs. microscopic hematuria vs.
gross hematuria
 3. Recognize common causes of microscopic hematuria and gross
hematuria
 4. Identify risk factors associated with hematuria
 5. Describe a systematic approach to hematuria evaluation in primary care
 6. Recognize when to refer to a specialist for further evaluation
 7. Discuss common hematuria work-up in Urology (for patient education
purposes)
HEMATURIA
The abnormal presence of blood or red blood
cells in the urine
hematuria. (n.d.) Farlex Partner Medical Dictionary. (2012). Retrieved July 1 2015 from
http://medical-dictionary.thefreedictionary.com/hematuria
Take Home Message:
Hematuria, visible or not, is a
red flag and warrants further
evaluation.
Dipstick Positive Heme/
hemoglobinuria:
 finding on dipstick urinalysis. Does not constitute MH;
should be confirmed or refuted with Microscopic
urinalysis. Ensure that this was a clean catch, midstream
voided specimen.
What do we do with a dipstick positive
heme urine….
Take home message
ALL dipstick positive heme urines warrant
microscopic urinalysis for confirmation of true or
false positive
Microscopic hematuria:
 > 3 red blood cells per high powered field (rbc/hpf) on two of three
specimens. (AUA)
Take Home Message:
 Microscopic hematuria without a clear etiology
(UTI/BPH/Prostatitis/Nephrolithiasis) warrants referral
to Urology for further evaluation if patient is deemed
at risk
 Microscopic hematuria with identifiable etiology
(UTI/BPH/Prostatitis/Nephrolithiasis) should have
follow up repeat microscopic urinalysis post
treatment to verify resolution.
Gross…So what does that mean?
 Gross Hematuria = Visible blood in the urine
 Bright red blood in the urine is typically of lower urinary
tract origin
 Smoky, hazy or reddish-brown coloration of urine is
typically of upper urinary tract origin (renal
parenchymal)
False Positives
 Myogobinuria
 Hemoglobinuria
 Medications that may cause red urine:
• Pyridium
Phenytoin (Dilantin)
• Sulfamethoxazole
Levodopa
• Nitrofurantoin
Methyldopa
• Rifampin
Quinine
• Ibuprofen
Chloroquine
• Phenacetin
Foods that may cause RED
pigmenturia
Rhubarb
Blackberries
Blueberries
Paprika
Beets
Fava Beans
*Cleveland Clinic*
Glomerular Hematuria
 Arising from the kidney itself (medical renal or
parenchymal) and typically evaluated/treated by
nephrology.
• IgA nephropathy (Berger's disease)
• Thin glomerular basement membrane disease
• Hereditary nephritis (Alport's syndrome)
 Findings suggestive of glomerular hematuria are:
significant proteinuria (2+ or greater), RBC casts and
dysmorphic RBCs.
Evidence of Glomerular Hematuria
Non Glomerular Hematuria
A condition arising from the upper or lower urinary tract resulting
from a structural or pathologic condition
Lower Tract
Upper Tract
•
Urolithiasis
•
Bacterial cystitis (UTI)
•
Pyelonephritis
•
Benign prostatic hyperplasia
•
Renal cell carcinoma
•
•
Transitional cell carcinoma
(kidney or ureters)
Strenuous exercise ("marathon
runner's hematuria")
•
Transitional cell carcinoma of the
bladder
•
Spurious hematuria (e.g. menses)
•
Instrumentation
•
Benign hematuria
•
Urinary obstruction
•
Benign hematuria
Common Causes of Microscopic
hematuria
 Urinary Tract Infection (UTI)
 Benign Prostatic Hyperplasia (BPH)
 Urinary Calculi
 Idiopathic familial microhematuria (43%)
 Always consider urinary tract malignancy until
proven otherwise
Up to 5% of patients with asymptomatic microscopic
hematuria will have a urinary tract malignancy
Kidney Cancers
Renal Cell Carcinoma (RCC):
The most common
type of kidney cancer. 9 out of 10 kidney cancers are RCC
Transitional Cell Carcinoma (TCC): AKA Urothelial
carcinomas, account for 5-10% of kidney cancers
Wilm’s tumors: almost always occur in children, very rare
in adults. 9 of 10 tumors will have favorable histology (nonanaplastic)and high cure rate.
Renal Sarcoma: Rare (less than 1% of all kidney
cancers)
Gross Hematuria
 Commonly associated with:
•
Urinary calculi- kidney, ureteral or bladder stones (irritative voiding sxs)
•
Severe UTI (irritative voiding sxs)
•
Strenuous exercise, especially long distance running and cyclists
•
Hemorrhagic cystitis- persistent or recurrent hematuria caused by bladder
inflammation. Often radiation or chemotherapy induced. Bleeding can
be severe.
•
Kidney trauma
•
Malignancy- renal, ureteral, prostatic, bladder, urethral (up to 23%)
•
BPH with bladder outlet obstruction
MNEUMONIC: PP ON THIS (with 4 Ts)
Differential Diagnosis
 P- Period (menses) aka: pseudohematuria
 P- Prostate- Prostatitis, BPH, prostate ca
 O- Obstructive Uropathy
 N- Nephritis- glomerulonephritis, Alport’s syndrome, Berger’s, interstitial nephritis
 T- Trauma
 T- Tumor
 T- Tuberculosis
 T- Thrombosis- renal vein thrombosis
 H- Hematologic- anticoagulation, coag disorders, sickle cell disease
 I- Infection/inflammation- UTI, pyelonephritis, interstitial cystitis, radiation cystitis
 S- Stones
Risk Factors Associated with Hematuria
 Age: > 40
 Sex: Male, esp. > 50 due to BPH
 Pelvic radiation
 Previous history of urologic disease and treatment
 Cigarette smokers: increased risk for urinary tract malignancy
 Irritative voiding symptoms (urgency, frequency, dysuria)
 Chemical exposures (cyclophosphamide, benzenes, aromatic amines)
American Urological Association Guidelines:
www.auanet.org
It’s the Aspirin….. Or is it?
Medications such as anticoagulants,
Aspirin, NSAIDs, chemotherapy and some
abx such as PCN may influence the
duration and severity of hematuria from
another cause but ARE NOT THE CAUSE
Evaluation in Primary Care
 A thorough Medical History:
•
•
•
•
Renal colic (ureteral stones, pyelonephrosis, ureteral obstruction)
fever (infection)
Irritative voiding symptoms (UTI, bladder or urethral stricture, bladder
tumor)
Obstructive voiding sxs ( BPH, tumor)
•
Recent infection: Kidney inflammation after a viral or bacterial infection
(post-infectious glomerulonephritis) is one of the leading causes of gross
hematuria in children.
•
Asymptomatic: menses, trauma, malignancy, medications, bleeding
disorder, dietary factors, vigorous physical activity
Prior pelvic radiation or chemotherapy
•
History continued
Timing
 Initial hematuria indicates anterior urethral bleeding
(urethritis, stricture, meatal stenosis)
 Terminal hematuria is more consistent with posterior
urethral bleeding (prostatitis, posterior urethritis, tumors of
bladder neck or trigone, polyps)
 Total hematuria indicates bleeding at or above the level
of the bladder (stones, tumors, cystitis, nephritis,
tuberculosis)
Social History
Cigarette smoking
Occupational exposures to aniline dyes or
aromatic amines used in certain manufacturing
processes which increase the risk of bladder
cancer
Family History
 Hereditary diseases: Alport’s syndrome, Berger’s IgA
nephropathy, Sickle cell disease, nephrolithiasis, urologic
cancers
 Idiopathic familial microscopic hematuria
Physical Exam
 CVA tenderness without fever may indicate kidney stone
 CVA tenderness with fever is more indicative of pyelonephritis
 Palpate abdomen for masses
 Palpable kidneys indicate hydronephrosis or renal mass
 Palpable bladder may indicate obstruction or retention
 Rectal exam may reveal tender, boggy prostate indicating prostatitis
 Edema: nephrotic syndrome
 Cardiac arrhythmia: atrial fibrillation; in the presence of flank pain and
hematuria should raise the possibility of renal embolic infarction
Diagnostics
 Microscopic urinalysis
 Urine culture if indicated
 Renal function testing if indicated (red cell casts=suspect
glomerular hematuria)
 Patients with gross hematuria or those with any of the risk
factors are considered high risk and should undergo a
thorough urologic evaluation.
 Patients with asymptomatic hematuria and no associated risk
factors are classified as low risk but still warrant urologic
evaluation.
The diagnostic studies selected depend on
the risk factors for significant disease.
 Imaging studies are used to evaluate the upper urinary tract
(kidneys and ureters)
 Urine cytology or direct endoscopic (cystoscopy)
visualization of the bladder and urethra can be used to
evaluate the lower urinary tract
 Low risk patients: Renal U/S and voided urine cytology (urine
cytology does not screen for renal cancer thus the renal U/S)
 High Risk patients: (gross hematuria or associated risk factors)
should undergo contrast-enhanced imaging of the kidneys
and ureters ( CT A&P) in addition to cystourethroscopy and
urine cytology.
Case Study: 22 y/o female
 HPI: Sudden onset of severe pain (10/10) in the right
lower back. Associated nausea and vomiting. No fever
or chills. No history of recent injury or illness. Has never
had back pain like this before. Feelings of extreme
urgency and voiding small amounts frequently. Denies
gross hematuria.
 PE: A+O x3. In obvious discomfort/distress. + CVA
tenderness on the right. Abdomen is unremarkable. No
suprapubic tenderness.
 Lab: Dipstick urinalysis is heme positive
Clinical Suspicion for Nephrolithiasis
 If nephrolithiasis is suspected, various imaging studies can be helpful. What
test should we order for further evaluation ( after r/o
pregnancy of course!)??
 Plain Abdominal film (KUB)is quick and noninvasive but beware that
small stones (less than 2mm) are easily missed. Uric acid stones are radiolucent
and will be missed. Overlying bowel gas and stool can hide stones as can bony
pelvic structures.
 Gold Standard for diagnosing urolithiasis is CT A&P without
contrast
 Management: depends on size and location of stone and/or
ability to control patient’s pain- ultimately, need to repeat
microscopic urinalysis once stone resolved
Case Study: 46 y/o male
 46 y/o male presents with complaints of painless, gross
hematuria intermittently x 2 weeks. Denies irritative voiding
symptoms- dysuria, frequency, urgency. Denies passage of
clots. Blood is bright red in color and present throughout the
stream. He has not had similar symptoms previously. History
of cigarette smoking- quit 6 years ago with a prior 2ppd
history. No prior history of prostatitis but has been told that his
prostate is mildly enlarged.
 PE: Unremarkable
 Lab: dipstick positive urinalysis for heme, microscopic
hematuria confirmed. No bacteria or significant proteinuria.
What would you do next???
This patient is high risk
Male gender
>40
Previous smoker
Refer to Urology for thorough evaluation!
Highly suspicious for urologic malignancy
Referral to Urology
Symptomatic or Not:
It is appropriate to refer to Urology any patient
with gross hematuria
Any at risk patient with proven Microscopic
Hematuria without a proven benign cause (UTI,
prostatitis) Urine C&S negative
Patient’s with persistent microhematuria despite
treatment of suspected UTI or prostatitis
Questions???
References
 Farlex Partner Medical Dictionary. (2012). Retrieved July 9 2015 from
http://medical-dictionary.thefreedictionary.com/hematuria
 Assessment of Asymptomatic Microscopic Hematuria in Adults VICTORIA J.
SHARP, MD, MBA; KERRI T. BARNES, MD, MPH; and BRADLEY A. ERICKSON, MD,
MS, University of Iowa Hospitals and Clinics, Iowa City, Iowa, Am Fam
Physician. 2013 Dec 1;88(11):747-754.
 http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/ne
phrology/evaluation-of-hematuria/Default.htm
 Urology: House Officer Series, 4th edition. Michael Macfarlane. Lippincott
Williams & Wilkins. 2007.
 Smith’s General Urology, 17th edition. Tanagho, Emil, McAninch, Jack. Lange.
2008.
 http://www.auanet.org/education/hematuria.cfm
 http://www.cancer.org/cancer/wilmstumor