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Evaluation of Hematuria Matthew Simmons, MD, PhD Urology Specialists of Oregon Bend, OR There’s blood in the urine: Now what? • How much blood warrants work-up? • What could be the cause? • What kind of evaluation is needed? History of Urinalysis • Urine was used to assess health 6000 years ago • In the Middle ages “Uroscopy” matched urine to a color chart to make a diagnosis Modern Urinalysis • Quantitative and rapid analysis • Detection of: – Blood – Ketones – Specific gravity – Glucose – Leukocytes – Bacteria What your patient sees • Hematuria – Invisible = Microscopic hematuria – Visible = Gross hematuria Initial Test: Urine dipstick analysis • Performed in uncentrifuged specimen • 95% sensitive • 75% specific • Abnormal results must be confirmed with microscopic evaluation Gross Hematuria • One episode is enough to warrant formal urological evaluation • Colors vary – be suspicious • Amount of blood doesn’t correlate to severity of problem Questions to ask • • • • • • • Painful or painless? Timing of bleeding? Dysuria? After exercise? After recent surgery or illness? Smoker? Period? Microhematuria • Conducted based on micro analysis of 10ml of urine spun 10 minutes at 2000RPM • Sediment is resuspended • Urine evaluated at 400X magnification Definition of Microhematuria • >3 RBCs per high power field present in 2 of 3 specimens • If criteria are met then the patient qualifies for a formal urology evaluation Teaching point • Patients require a formal evaluation if they have: – Microhematuria = 3 RBCs per HPF in 2 studies – Gross hematuria of any kind Causes • • • • • Medical Infectious Obstructive Malignant Treatment-related What is a formal evaluation? • Upper tract imaging • Cystoscopy • (Cytology) • Purpose is to rule identify cause as benign or pathologic Imaging • CT-Urogram > CT with & without IV contrast > non-contrast CT • MRI does not detect stones, is costly • Renal US is sufficient but provides lower reliability data Concerns with imaging • Cost • Underlying kidney disease • Radiation exposure (especially in minors or women of reproductive age) Cystoscopy • Only way to accurately assess bladder for stones, tumors or other abnormalities • An office procedure Urine cytology • High cost • Low sensitivity, high specificity • Only indicated in specific cases Teaching Point • Formal evaluation for hematuria is: – Upper tract imaging – Cystoscopy – Urine cytology used to be part of formal evaluation but is now only done is specific cases UTIs • Uncomplicated – Urinary frequency, urgency, dysuria • Complicated – Fever, chills, flank pain UTI Pathology • Bactria grow in urine, adhere to epithelial cells and trigger an immune response • Associated with: – Intercourse (Introduction of bacteria) – Vulvar atrophy (Lessened immunity) – Incomplete emptying (Inability to clear) – Foreign bodies, stones (Nidus for infection) Hematuria and UTIs • Always send urine for culture • Treat the UTI and repeat the UA 3-4 weeks afterwards and in absence of lower tract symptoms • If they meet criteria for microhematuria or have repeat gross hematuria then evaluation is needed Stones • Common cause of microscopic and gross hematuria – Prior history of stones? – Associated pain? Stones • Kidney, ureter or bladder • Calcium oxalate, uric acid, struvite • Concurrent UTI or renal failure? BPH • Common benign cause of hematuria in older men • Due to turbulent flow and friable blood vessels • A diagnosis of exclusion Incomplete emptying • Can be due to kidney/ureter obstruction (UPJO, stricture, tumor) • Can be due to lower tract obstruction (BPH, diverticuli, tumor) • Obstruction can lead to UTI or tumors Tumors • Most important diagnosis to rule out • Can be renal primary (RCC) • Can be urothelial – Arise from collecting system, ureter and bladder Renal tumors • Renal cell carcinoma • Arise from kidney tissues • Diagnosis confirmed by presence of contrast enhancement Urothelial Tumors • Can be located in kidney, ureter or, most commonly, bladder • Cystoscopy assesses for papillary tumors or CIS Medical Renal Causes • • • • IgA Nephropathy Thin Basement Membrane Disease Benign Familial Microhematuria Glomerulonephritis Clues for Medical Renal Causes • • • • Elevated creatinine Proteinuria or glucosuria Negative formal evaluation Specific microscopic findings Cystitis • Interstitial cystitis – Dx of exclusion, Rare, Hallmark is pain with urination in absence of infection • Radiation cystitis – Common in men 5-10 years after prostate RT Anticoagulation • Will not cause de novo hematuria • Usually unmasks an underlying problem such as tumor or stone Imposters • • • • Myoglobin (myoglobinuria) Porphyin (porphyria) Betanin (from beets) Rifampin, Pyridium medications Summary • Gross hematuria always warrants evaluation • Microhematuria is >3RBCs/HPF on 2 studies • Formal evaluation consists of upper tract imaging and cystoscopy • When in doubt, refer!