Hematuria Information

1. 1

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 three red blood
cell
2

3. According to the amount of RBC in the
urine, hematuria can be classified as:
 Microscopic hematuria:
normal colour with eyes
 Gross hematuria:
tea-colored, cola-colored, pink or
even red
3

4. ETIOLOGY
Diseases of the urinary system
I Vascular
Arteriovenous malformation
Arterial emboli or thrombosis
Arteriovenous fistula
Renal vein thrombosis
Loin-pain hematuria syndrome
Cogulation abnormality
Excessive anticogulation
4

5. ETIOLOGY
II Glomerular
IgA nehropathy
Thin basement membrane disease (incl.Alport syndrome)
Other causes of primary & secondary glomerulonephritis
III Interstitial
Allergic interstitial nephritis
Analgesic nephropathy
Renal cystic diseases
Acute pyelonephritis
Tuberculosis
Renal allograft rejection
5

6. ETIOLOGY
IV Uroepithelium
Malignancy
Vigorous exercise
Trauma
Papillary necrosis (common in DM and sickle cell trait/disease)
Cystitis/Urethritis/Prostatitis(usually caused by infection)
Parasitic diseases (e.g. schistosomiasis)
Nephrolithiasis or bladder calculi
V Multiple sites or source unknown
Hypercalciuria
Hyperuricosuria
6

7. ETIOLOGY
System disorders
a. Hematological disorders
Aplastic anemia Leukemia
Allergic purpura Hemophilia
ITP (idiopathy thrombocytopenic purpura)
b. Infection
Infective endocarditis
Septicemia
Epidemic hemorrhagic fever (Hantaan virus)
Scarlet fever (-hemolytic streptococcus)
Leptospirosis (leptospire)
Filariasis (Wuchereria bancrofti, Brugia malayi)
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8. ETIOLOGY
c. Connective tissue diseases
Systemic lupus erythematosus (SLE)
Polyarteritis nodosa
d. Cariovascular diseases
Hypertensive nephropathy
Chronic heart failure
Renal artery sclerosis
e. Endocrine and metabolism diseases
Gout
Diabetes mellitus
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9. ETIOLOGY
Diseases of adjacent organs to urinary tract
Appendicitis , Salpingitis
Carcinoma of the rectum
Carcinoma of the colon
Uterocervical cancer
Drug and chemical agents
Sulfanilamides, Anticogulants
Cyclophosphamide, Mannitol
Miscellaneous
Exercise, “idopathic” hematuria
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10. CLINICAL FEATURES
 Color
depends on the amount of red blood cell in the
urine and the pH
normal: light yellow, pH 6.5
 pH
acidic: more darker (brown or black)
alkaline: red
10

11. DIFFERENTIAL DIAGNOSIS
 Contaminated urine: menstruation
 Drug and food: phenosulfonphthalein (PSP),uric
acid, vegetable
 Porphyrism: porphyrin in urine (+)
 Hemoglobinuria
11

12. 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, posturethra
 all the specimens containing RBC—upper urinary
tract, bladder
12

13. ACCOMPANIED SYMPTOMS
 Hematuria with renal colic
Renal stone, ureter stone
If with dysuria, micturation pause or straining to void:
bladder or urethral stone
 Hematuria with urinary frequency, urgency
and dysuria
Bladder or lower urinary tract (tuberculosis or tumor)
If accompanied by high spiking fever, chill and loin
pain: pyelonephritis
13

14.  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
14

15. --Approaching to the patient–
(Harrison’s Principle of Internal
Medicine,14th Ed)
HEMATURIA
proteinuria (>500mg/24h)
Dysmorphic RBC or RBC casts
Pyuria,WBC casts urine culture
eosinophils serologic and hematologic
evaluation: blood culture,
anti-GBM Ab, ANCA,
complement, cryoglobulin
HBV,HCV,VDRL,HIV, ASLO
renal biopsy
Hb electrophoresis, urine cytology,
UA of family member, 24h urinary
calcium/uric acid
IVP+/-renal
ultrasound
As indicated:
retrograde
pyelography or
arteriogram of cyst
aspiration
cystoscopy
CT scan
biopsy
open renal biopsy
follow
(-)
(-)
(-)
(-)
(-)
(-)
(+)
(+)
(+)
(+)
(+)
ANCA:antineutrophil cytoplasmic
antibody, VDRL:venereal dis.
research laboratory, ASLO:
antisteptolysin O, IVP:
intravenous pyelography 15

16. Glomerular V/s Extraglomerular
bleeding
Urinary finding Glomerular Extraglomerular
Red cell casts May be present Absent
Red cell
morphology
Dysmorphic Uniform
Proteinuria May be present Absent
Clots Absent Absent
Color May be red or
brown
May be red
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17. Renal causes of Hematuria
Glomerular
- Acute Postinfectious Glomerulonephritis
- IgA Nephropathy
- Hereditary Nephritis ( Alport syndrome)
- Benign Recurrent or Persistent Hematuria (Thin
Membrane Disease)
1.Sporadic
2.Familial
- Membranoproliferative Glomerulonephritis
- Crescentic Glomerulonephritis
- Lupus Nephritis
- Nephritis of Henoch-Shönlein Purpura
- Focal Glomerulosclerosis
- Hemolityc-Uremic Syndrome
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18. Renal causes of Hematuria
Non-glomerular
- Infection ( Pyelonephritis )
- Interstitial Nephritis
- Metabolic ( Uric Acid, Nephrocalcinosis )
- Renal Malformation ( Cystic Kidney )
- Tumors ( Wilm’s, Acute Leukemia)
- Idiopatic Hypercalciuria
- Trauma
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19. Causes of urinary tract related
Hematuria
Infection
Urolithiasis/Stone
Obstruction ( UPJ Stenosis )
Trauma
Drugs ( Cyclophosphamide )
Tumors/Neoplasm
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20. Evaluation of Hematuria
History
Detailed review of family history
hematuria
proteinuria
renal insufficiency
stones
Precipitating factors
infection
exercise
Abdominal pain
hydronephrosis
pyelonephritis
urolithiasis
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21. Evaluation of Hematuria
Physical Examination
Growth failure
Hypertension
Pallor
Edema
Rash
Abdomen: search for a mass or tenderness
External genitalia: bleeding
infection
trauma
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