Hematuria for undergraduates this is a presentation i prepared for medical students about hematuria, hope u like it for more urology resources visit: www.uronotes2012.blogspot.com

1. Urology Department
Under-graduate courses
Hematuria
M.A.Wadood Aref

2. DEFINITION
More than three red blood cells are found in
centrifuged urine per high-power field
microscopy ( > 3 RBC/HP).
Normal urine:
no red blood cell or less than 3 red blood cell

3. Classification
According to the amount of RBC in the
urine, hematuria can be classified as:
• gross hematuria (visible) • microscopic hematuria
tea-colored, cola-colored, pink or normal colour with eyes
even red

4. Classification
Another classification by Timing (when it occurs
during urination), which may indicate the location of
the problem.
Initial hematuria: Onset of urination – urethra.
Total hematuria: Throughout urination – bladder,
ureter, or kidneys.
Terminal hematuria: End of urination – bladder or
prostate (men).

5. ETIOLOGY
 Diseases of the urinary system— the most
common cause
a- Glomerular
b- Interstitial
c- Uroepithelium
d- Vascular

6. ETIOLOGY
Glomerular
IgA nehropathy
1ry and 2ry glomerulonephritis
Interstitial
Allergic interstitial nephritis
Analgesic nephropathy
Renal cystic diseases
Acute pyelonephritis
Tuberculosis
Renal allograft rejection

7. ETIOLOGY
Uroepithelium
Malignancy
Trauma
Papillary Necrosis
Cystitis/Urethritis/Prostatitis
Parasitic Diseases (Schistosomiasis)
Stones
Vascular
Arterial emboli or thrombosis
Arteriovenous fistulae
Renal vein thrombosis

8.  System disorders (less common)
a. Hematological disorders
aplastic anemia - leukemia - hemophilia -
ITP (idiopathy thrombocytopenic purpura)
b. Infection
infective endocarditis - septicemia - epidemic
hemorrhagic fever - scarlet fever - filariasis
c. Connective tissue diseases
SLE - polyarteritis nodosa
d. Cariovascular diseases
hypertensive nephropathy- chronic heart failure -
renal artery sclerosis
e. Endocrine and metabolism diseases
gout - diabetes mellitus

9.  Diseases of adjacent organs to urinary
tract
appendicitis
carcinoma of the rectum
carcinoma of the colon
uterocervical cancer
 Drug and chemical agents
anticogulation cyclophosphamide
 miscellaneous
exercise induced hematuria

10. DIFFERENTIAL DIAGNOSIS
• Polluted urine: menstruation
• Drug and food: Rifampicin, Nitrofurantoin,
sulfonamides, adriamycin.
• Porphyria: porphyrin in urine (+)
• Hemoglobinuria (hemolysis)
• Myoglobinuria

11. ACCOMPANIED SYMPTOMS
• Hematuria with renal colic
renal stone, ureteric stone.
• Hematuria with urinary frequency,urgency
and dysuria
bladder or lower urinary tract (TB or tumor)
If accompanied by high spiking fever, chill and loin
pain: pyelonephritis

12. ACCOMPANIED SYMPTOMS
• Hematuria with edema and hypertension
glomerulonephritis - hypertensive nephropathy
• Hematuria with mass in the kidney
neoplasm - hereditary polycystic kidney
• Hematuria with hemorrhage in skin and
mucosa
hematological disorders - infectious diseases
• Hematuria with chyluria filariasis

13. Workup of Hematuria
• Investigation are crucial to exclude serious
underlying conditions, especially urinary tract
neoplasm.
• Patients on anticoagulants should also be
investigated. Anticoagulants are more likely to
provoke rather than be the cause of hematuria.
• Full urological History
• Physical exam: of urinary tract, abdomen, pelvis,
genitals, and rectum.
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14. Workup of Hematuria - Lab
• Urinalysis & 3 glass test: for protein, RBCs, RBC
casts, bacteria
• Phase contrast microscopy: for RBCs morphology
• Cytology: for exfoliated malignant cells.
• Creatinine
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15. Workup of Hematuria –
Radiology & procedures
• Imaging studies:
 Ultrasound: primary investigation
 IVU: standard investigation (old).
 CT urography: now replaces IVU.
 MRI.
 Retrograde pyelography.
• Renal biopsy: in nephrological cases
• Cystoscopy
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16. LABORATORY TESTS
 Three-glass test
Method: collecting the three stages of urine of
a patient during micturition
Result:
 the initial specimen containing RBC—the urethra.
 the last specimen containing RBC—the bladder.
neck and trianglar area, post. Urethra.
 all the specimens containing RBC—upper urinary
tract, bladder.

17. LABORATORY TESTS
Phase-contrast microscopy
to distinguish glomerular from post
glomerular bleeding
• Post glomerular bleeding:
normal size and shape of RBC
• Glomerular bleeding:
dysmorphic RBC (acanthocyte)

18. LABORATORY TESTS
Example Of Phase-contrast Microscopy Test
Non-Glomerular Glomerular (dysmorphic RBCs)

19. HEMATURIA Algorithm
proteinuria (>500mg/24h)
(-) Dysmorphic RBC or RBC casts
(+)
(+)
Pyuria,WBC casts urine culture
eosinophils
(-) serologic and hematologic
evaluation: blood culture,
Hb electrophoresis, urine cytology, anti-GBM Ab, ANCA,
UA of family member, 24h urinary complement, cryoglobulin
calcium/uric acid HBV,HCV,VDRL,HIV,
(-) As indicated: ASLO
(+)
IVP+/-renal retrograde
ultrasound pyelography or
renal biopsy
(-) arteriogram of cyst
(+) aspiration
cystoscopy
(-) biopsy ANCA:antineutrophil cytoplasmic
(+) antibody, VDRL:venereal dis.
CT scan research laboratory, ASLO:
(-) open renal biopsy antisteptolysin O, IVP: intravenous
follow pyelography

20. Thank You