Hematuria - causes and evaluation

HEMATURIA –CAUSES
AND
EVALUATION
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai

Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC, Chennai. 2

Hematuria
• Gross or Macroscopic or Visible-the single observation of visible urine
discoloration due to the presence of blood (> 2500 RBCs / μl)
• Microscopic - when the urine is visually normal in color but is found to contain
blood on chemical analysis or microscopic evaluation.
• Asymptomatic microhematuria (AMH) - is defined as, 3 or greater RBCs / HPF
on a properly collected urinary spun specimen in the absence of an obvious
benign cause. (single urinary specimen)
• Normal excretion rate is : 0.5 to 2 million RBCs/24 hr
3
Dept of Urology, GRH and KMC, Chennai.

• Cyclic hematuria- in women that is most prominent during
and shortly after menstruation, suggesting endometriosis
of the urinary tract.
• Sterile pyuria with hematuria- renal tuberculosis, analgesic
nephropathy and other interstitial diseases
• Loin pain-hematuria syndrome (LPHS)- (rare) a poorly
defined disorder; recurrent episodes of severe unilateral or
bilateral loin (flank) pain that were accompanied by gross
or microscopic hematuria with dysmorphic red cell features
suggesting a glomerular origin; associated with somatoform
disorders and use of OCPs. Affected patients usually have
normal kidney function.
4

• Exercise induced hematuria: Gross or microscopic
hematuria that occurs after strenuous exercise
and resolves with rest
•Direct trauma to the kidneys and/or bladder
may be responsible for the hematuria
•Renal ischemia due to shunting of blood to
exercising muscles
Evaluation for other causes of hematuria is
warranted if the hematuria persists well beyond
one week
5

Hematuria Dysuria syndrome: presence of Hematuria and
dysuria after Gastrocystoplasty, seen in 36% of the cases.
▪ 14% of patients required treatment with medications.
▪ signs and symptoms are most likely secondary to acid
irritation.
▪ It is imperative to achieve reliable urinary continence in
patients undergoing gastrocystoplasty because urinary
leakage may result in the exposure of the skin(meatal) to
gastric secretions and in gastric secretions that are poorly
diluted. Dilution is important
▪ respond well to H2 blockers and hydrogen ion pump
blockers.
▪ Bladder irrigation with baking soda may also be effective.
6

• Nutcracker syndrome hematuria: can cause both
microscopic and gross hematuria, primarily in children
(but also adults) in Asia .
usually asymptomatic but may be associated with left
flank pain; also been associated with orthostatic
proteinuria.
• Benign essential hematuria: no obvious source of
hematuria can be identified through conventional
studies. Frequent bouts of GH with clots and colic +
usual causes are small venous abnormalities/
hemangiomas. CT/MRI are initial studies but low yield;
Better seen on UT endoscopic inspection.
7

• - variable course of urethritis
• - blood spotting in prepubertal boys
• - hormonal factors combined with inflammation
• If normal phy.exam. & neg. urine C/S – no further
evaluation needed
• If stricture is suspected do cystoscopy & VCU
• REITER’s syndrome – arthritis, conjunctivitis
Idiopathic urethrorrhagia
8

WHAT to look FOR ?
• Gross or microscopic.
• Timing of hematuria: Initial or total or terminal.
• Associated loin pain.
• Presence or absence of clot
• Clot characteristics.
9

BASED ON TIMING
• Indicates the site of origin.
• Initial hematuria - arises from the
urethra ,secondary to
inflammation.
• Total hematuria – most common
anywhere from the bladder or
upper urinary tracts.
• Terminal hematuria- end of
micturition, secondary to
inflammation in the bladder neck,
trigone or prostatic urethra
10

Duration of Hematuria
• Transient Hematuria
Benign & without any obvious etiology in 39% of
young adults
• 8-9% of adults >50yr – malignancy
• Persistent Hematuria
Defined as three positive urinalyses, based on a
test strip and microscopic examination, over a 2 to
3 week period
• Microscopic – 5% malignancy • Macroscopic –
20% malignancy
11

ASSOCIATION WITH PAIN
• Due to inflammation or obstruction.
• Usually results from upper urinary tract hematuria with
obstruction of the ureters with clots.
12

Associated with CLOTS. ?
Clot indicates a more significant degree of hematuria.
Amorphous
signifies bladder or prostatic urethral origin.
vermiform (wormlike) clots
associated with flank pain signifies origin from upper
urinary tract with formation of vermiform clots within
the ureter.
13

Pathophysiology:
• Structural disruption in the integrity of
glomerular basement membrane caused by
inflammatory or immunologic processes
• Toxic disruptions of the renal tubules
• Mechanical erosion of mucosal surfaces in the
genitourinary tract
14

Characteristics of urine:
• Amount of urine: Reduced in AGN, ARF
• Clots in urine: Extraglomerular
• Frequency, Dysuria, recent enuresis : UTI
• Frothy urine: Suggests Proteinuria seen in
Glomerular diseases
15

Physical Examination Findings and Associated Causes of
Hematuria
Physical examination finding Cause of hematuria
General (systemic) examination
Severe dehydration Renal vein thrombosis
Peripheral edema Nephrotic syndrome, vasculitis
Cardiovascular system
Myocardial infarction Renal artery embolus or thrombus
Atrial fibrillation Renal artery embolus or thrombus
Hypertension Glomerulosclerosis with or without
proteinuria
Abdomen
Bruit Arteriovenous fistula
Genitourinary system
Enlarged prostate Urinary tract infection
Phimosis Urinary tract infection
Meatal stenosis Urinary tract infection
16

1. Concurrent pyuria and dysuria, indicate UTI, may also occur with
bladder malignancy.
2. A recent URI, raise the possibility of either post infectious
glomerulonephritis or IgA nephropathy
3. A positive family history of renal disease give suspicion of
hereditary nephritis, polycystic kidney disease, Alports syndromes,
or sickle cell disease.
Clues from the history that point toward a specific
diagnosis
17

• 4. Unilateral flank pain radiating to the groin, suggesting
ureteral obstruction due to a calculus or blood clot, but
can occasionally be seen with malignancy. Flank pain that
is persistent or recurrent can also occur in the rare loin
pain hematuria syndrome.
• 5. Symptoms of prostatic obstruction in older men such as
hesitancy and dribbling. The cellular proliferation in BPH is associated with increased
vascularity, and the new vessels can be fragile.
18

6. Recent vigorous exercise or trauma
7. History of a bleeding disorder or bleeding from multiple sites
due to uncontrolled anticoagulant therapy.
8. Cyclic hematuria in women
9. Medications that might cause nephritis (usually with other
findings, typically with renal insufficiency).
19

• 10. sickle cell trait or disease, which can
lead to papillary necrosis and
hematuria.
• 11. Travel or residence in areas endemic
for Schistosoma hematobium .
20

Work –up
Laboratory Studies :
• Urinalysis
• Phase contrast microscopy
• BUN/serum creatinine: Elevated levels of BUN and creatinine suggest significant
renal disease as the cause of hematuria
• Hematologic and coagulation studies: CBC counts
, Platelet counts
• Urine calcium : calcium excretion of more than 4 mg/kg/d or a urine calcium-
creatinine ratio of more than 0.21 are considered abnormal.
• Serologic testing
• Urine culture
21

22

Renal Biopsy
A biopsy is not usually performed for isolated
glomerular hematuria (i.e., no proteinuria or renal
insufficiency,) since there is no specific therapy for
these conditions
It is considered if there is evidence of progressive
disease (elevation in the plasma creatinine
concentration, increasing protein excretion) or an
otherwise unexplained rise in blood pressure, even
when the values remain within the normal range
23

24

25

3 container urine test:
Done in MH cases; can provide information on site of
origin of erythrocytes.
• Initial/VB1 – 10 to 15ml of initial urine(ant.Urethra )
• Middle/VB2- 30 to 40 ml of middle portion
• Final – last 5-10 ml of urine ( bladder neck / post. Urethra ).
Presence of equal numbers of RBCs in all 3 containers – indicate
bleeding above bladder neck ( UUT).
3 container test not needed in pts with gross
hematuria.
26

27

28

Centrifuged urine
• In hemoglobinuria, the supernatant will be pink. This is
because free hemoglobin in the serum binds to
haptoglobin, which is water insoluble and has a high
molecular weight. This complex remains in the serum,
causing a pink color. Free hemoglobin will appear in
the urine only when all of the haptoglobin-binding sites
have been saturated.
• In myoglobinuria, the myoglobin released from muscle
is of low molecular weight and water soluble. It does
not bind to haptoglobin and is therefore excreted
immediately into the urine. Therefore, in
myoglobinuria the serum remains clear.
29

DIPSTICK EVALUATION
• Short, plastic strips impregnated with different chemical
reagents that react with abnormal substances in blood to
produce colorimetric reaction.
• Abnormal substances that commonly tested with a dipstick
are blood, protein, glucose, ketones, WBCs, urobilinogen and
bilirubin.
• It can detect trace amounts of hemoglobin and myoglobin.
• Can detect 5-10 intact RBC per mm3 of unspun urine
30

• A positive dipstick for blood in the urine indicates either
hematuria, hemoglobinuria, or myoglobinuria.
• Based on peroxidase activity of hemoglobin.
• The reagent strip that detects blood utilizes hydrogen
peroxide, which catalyzes a chemical reaction(oxidation)
between hemoglobin (or myoglobin) and the
chromogen tetramethylbenzidine > colour change.
• Different shades of blue-green are produced according
to the concentration of hemoglobin in the urine
31

32

33

• Sensitivity of urinary dipstick in identifying hematuria is 90%, but specificity is low
compared to microscopic examination.
• False positive:
- contaminated urine with menstrual bood,
- high specific gravity urine ( dehydration)
- after exercises/sexual activity.
- Urine pH >9, bacterial peroxidase, oxidizing agents
• False negative:
- formalin. Improper method
34

• Efficacy of hematuria screening using dipstick test in
urological disease is – low.
• Before proceeding to any complicated studies,
dipstick test must be confirmed by microscopic
examination of urinary sediment.
35

Urine microscopy
• acidic and concentrated early morning urine (EMU)
samples are more likely to detect red blood cells (RBC), and
casts; are best preserved in such a medium.
• Analysis should follow rapidly, preferably within 1 hour for
sediment analysis and 2 hours for dipstick testing.
• store at a temperature of 4˚C if a delay is encountered and
analyze as soon as possible
• Quantification tecniques:
1) Sediment count: spinning urine down in centrifuge with
supernant removed. The pellet of cells is then
resuspended in saline and examined under microscope.
2) Chamber count: detects no. of RBCs/ml of urine.
36

• About 10–15 mL is centrifuged at 3,000 rpm for 5 minutes,
with the supernatant subsequently discarded
• 0.01–0.02 mL of the residual sediment is placed directly on
the microscope slide and covered with a coverslip
• Microscopy examination done at both low power (×100)
and high power (×400).
• Low-power magniﬁ cation is adequate for the identiﬁcation
of most cells, macrophages, and parasites
• high-power is required to discriminate between circular
and dysmorphic RBC, and to identify crystals, bacteria, and
yeast
• one HPF represents 1/30,000 mL and false negatives, due
to this volume constraint, are therefore inevitable.
37

Phase-contrast microscopy
• to distinguish glomerular from post
glomerular bleeding
38

39

Causes of Hematuria
• Glomerular
• Non glomerular
Medical/renal
Surgical
/essential
1.Tubulointerstitial
2.Renovascular
3.Systemic
1.Calculi
2.UTI
3.Tumours
40

41

DIFFERENCE
NON GLOMERULAR GLOMERULAR
COLOUR RED OR PINK RED,SMOKY BROWN
OR COLA COLOUR
CLOTS MAY BE PRESENT ABSENT
PROTEINURIA < 500 MGS/DAY > 500 MGS/DAY
RBC MORPHOLOGY Round / circular DYSMORPHIC
RBC CASTS ABSENT MAY BE PRESENT
42

Glomerular hematuria
• Characterised by
- Dysmorphic RBCs, ( phase contrast microscopy )
- RBC casts,
- Significant Proteinuria.
43

GLOMERULAR CAUSES
• Ig A nephropathy (Berger disease)- MOST COMMON
• Mesangioproliferative GN
• Focal segmental proliferative GN
• Familial nephritis- ALPORTS
• Membranous GN
• Mesangiocapillary GN
• Focal segmental sclerosis
• Systemic lupus erythematous
• Post infectious GN
• others
Renal biopsy is needed for precise diagnosis. 44

45

EVALUATION-GLOMERULAR HEMATURIA
46

Non glomerular hematuria
• Charecterised by
- round/ circular RBCs
- absence of erythrocyte casts
• - with significant proteinuria – in nonglomerular
medicorenal / systemic hematuria.
( or)
• - absent proteinuria- in nonglomerular surgical /
essential hematuria.
47

NON GLOMERULAR CAUSES
1) Upper Urinary tract
a) Tubulointerstitial
• Pyelonephritis
• Papillary necrosis
• Interstitial nephritis
• Nephrotoxins- drugs
• Cystic diseases ( MSK / PCKD)
• Hydronephrosis
• Acute tubular necrosis
• Nephrocalcinosis
48

b) Anatomic:
• Hydronephrosis
• Polycystic kidney disease
• Tumor (Wilms, Rhabdomyosarcoma,
Angiomyolipoma)
• Trauma
49

c) Vascular:
• Sickle cell disease/trait
• Renal vein /artery thrombosis
• AV malformation (aneurysms, hemangioma)
• Malignant hypertension
• Coagulopathy/ hemophilia
• Thrombocytopenia
• Systemic anticoagulation
• Nutcracker syndrome
Crystalluria: Calcium, Oxalate, Uric acid
Medications: NSAIDs, anticoagulants
50

51

2) Lower urinary tract:-
• infectious and non infectious Cystitis
• Urethritis
• Urolithiasis
• Trauma
• Coagulopathy
• Heavy exercise
• Bladder tumor
• Factitious syndrome / by proxy
52

NON GLOMERULAR
HEMATURIA
Q
53

54

NON GLOMERULAR /ESSENTIAL/ surgical
hematuria
• Infection
• Hemorrhagic cystitis
• Urethritis
• Nephrolithiasis
• Hypercalciuria
• Obstruction
• Tumor.
55

ESSENTIAL HEMATURIA
56

Microscopic Hematuria evaluation
• Prevalence of MH in population is 6.5 %.
• One third to two third of patients evaluated for MH have
underlying cause like calculus, infection, inflammation, BPH, MRD,
congenital/ acquired anatomical abnormality and neoplasms.
• Malignancy has been detected in approx 4 % of patients.
• chance of malignancy is higher among the patients with
high levels of MH >25RBC/HPF, GH, or risk factors.
57

58

59

AUA guidelines for AMH
• A positive dipstick does not define AMH, and
evaluation should be based solely on findings
from microscopic examination of urinary
sediment and not on a dipstick reading.
• A positive dipstick reading merits microscopic
examination to confirm or refute the diagnosis
of AMH. Expert Opinion
60

• The assessment of the AMH patient should
include a: –careful history
–physical examination
–laboratory examination
to rule out benign causes of AMH such as
infection, menstruation, vigorous exercise,
medical renal disease, viral illness, trauma, or
recent urological procedures. Clinical Principle
61

• Once benign causes have been ruled out, the
presence of AMH should prompt a urologic
evaluation (Evidence Strength Grade C)
• At the initial evaluation, an estimate of renal
function should be obtained (may include
calculated eGRF, creatinine, and BUN) because
intrinsic renal disease may have implications for
renal related risk during the evaluation and
management of patients with AMH. Clinical
Principle
62

• The presence of dysmorphic RBs, proteinuria, cellular
casts, and/or renal insufficiency, or any other clinical
indicator suspicious for renal parenchymal disease
warrants concurrent nephrologic workup but does not
preclude the need for urologic evaluation.
(Evidence Strength Grade C)
• Microhematuria that occurs in patients who are taking
anti-coagulants requires urologic evaluation and
nephrologic evaluation regardless of the type or level
of anticoagulation therapy.
63

• For the urologic evaluation of asymptomatic
microhematuria, a cystoscopy should be performed on
all patients aged 35 years and older.
Recommendation(Evidence Strength Grade C)
• In patients younger than age 35 years, cystoscopy may
be performed at the physician's discretion.
Option (Evidence Strength Grade C)
• Regardless of age, A cystoscopy should be performed
on all patients who present with risk factors for urinary
tract malignancies (e.g., irritative voiding symptoms,
current or past tobacco use, chemical exposures)
Clinical Principle
64

65

• The initial evaluation for AMH should include a
radiologic evaluation:
• Multi-phasic computed tomography (CT)
• Urography (without and with intravenous (IV)
contrast)
including sufficient phases to evaluate the renal
parenchyma to rule out a renal mass and an excretory
phase to evaluate the urothelium of the upper tracts, is
the imaging procedure of choice because it has the
highest sensitivity and specificity for imaging the upper
tracts.
Recommendation (Evidence Strength Grade C)
66

• For patients with relative or absolute
contraindications that preclude use of
multiphasic CT (such as renal insufficiency,
contrast allergy, pregnancy): magnetic
resonance urography (MRU) (without/with IV
contrast) is an acceptable alternative imaging
approach.
67

contraindications that preclude use of
multiphase CT (such as renal insufficiency,
contrast allergy, pregnancy) where collecting
system detail is deemed imperative: (MRI)
with retrograde pyelograms (RPGs) provides
alternative evaluation of the entire upper
tracts
Expert Opinion
68

contraindications that preclude use of multiphase
CT (such as renal insufficiency, contrast allergy)
and MRI (presence of metal in the body) where
collecting system detail is deemed imperative:
combining non-contrast CT or renal ultrasound
(US) with retrograde pyelograms (RPGs) provides
alternative evaluation of the entire upper tracts.
Expert Opinion
69

• The use of urine cytology and urine markers
(NMP22, BTA-stat, and UroVysion FISH): is NOT
recommended as a part of the routine evaluation
of the AMH patient.
Recommendation (Evidence Strength Grade C)
• In patients with persistent microhematuria
following a negative work up or those with other
risk factors for carcinoma in situ (e.g., irritative
voiding symptoms, current or past tobacco use,
chemical exposures): cytology may be useful.
70

• Blue light cystoscopy : should not be used in the
evaluation of patients with SMH.
• If a patient with a history of persistent AMH has 2
consecutive negative annual urinalyses (one per
year for two years from the time of initial
evaluation or beyond): then No further urinalyses
for the purpose of evaluation of AMH are
necessary.
Expert Opinion
71

• For persistent AMH after negative urologic
work up: Yearly urinalyses should be
conducted.
Recommendation (Evidence Strength Grade
C)
• For persistent or recurrent AMH after initial
negative urologic work-up: Repeat evaluation
within 3-5 years should be considered.
Expert Opinion
72

Gross hematuria evaluation
• 50 % have demonstrable cause, with 25% found to
have urological malignancy.
• All patients must be evaluated with cystoscopy,
cytology and imaging CTU.
73

Common causes of Gross hematuria:
• Trauma
• Tumor
• Urolithiasis/hypercalciuria
• Urinary tract infection
• Meatal stenosis
• Perineal irritation
• Coagulopathy
74

Causes of Hematuria in the Newborn:
• Renal vein thrombosis (Asphyxia, dehydration, shock)
• Renal artery thrombosis
• Autosomal recessive polycystic kidney disease
• Obstructive uropathy
• Urinary tract infection
• Bleeding and clotting disorders
• Trauma, bladder catheterization
• Cortical necrosis (Hypoxic/ischemic perinatal insult)
• Nephrocalcinosis (Frusemide in premature)
75

Causes of INTRACTABLE
HEMATURIA
• Radiation cystitis
• Carcinoma bladder
• Cyclophosphamide induced cystitis
• Severe infection
Most pts will be elderly & not fit for cystectomy
76

TREATMENT AVAILABLE
77

INTRAVESICAL ALUM IRRIGATION
• It was first introduced by Floyd Csir in 1982.
• 1% alum solution (aluminum ammonium sulphate or
aluminum ammonium phosphate )was given intravesically
through 3 way Foley catheter.
• Alum works by astringent action of protein precipitation on
the cell surface & superficial interstial space.
• It leads to decreased permeability ,vasoconstriction
&reduction of edema.
• Aluminum toxicity may occur in renal failure patients & who
have large tumour surface area.
78

INTRAVESICAL HELMSTEIN’S HYDROSTATIC
PRESSURE
• It works by simple tamponade mechanism
• By increasing the Intravesical pressure , the blood flow
to bladder was decreased & haematuria was stopped.
• The tip of the Foley catheter was cut & it is attached to
the balloon or condom at the distal end, so that the
Foley balloon could be inflated within the balloon.
• Under epidural aneasthesia the balloon was introduced
into the bladder &filled with sterile water above 10 to
25 cm of water of diastolic BP.
• It is kept for 6 hours & removed.
• Serious complication is bladder rupture & patient will
have severe abdominal pain
79

INTRAVESICAL FORMALIN THERAPY
• Formalin precipitates the cellular proteins of bladder
mucosa & cause edema & tissue necrosis.
• Under spinal aneathesia the bladder is filled with 1 to
2% of formalin & contact time is 15 minutes.
• The success rate is 80 %.
• Complications are small contracted bladder,ureteric
stricture,vesicovaginal fistula,toxic effect on
myocardium & bladder rupture.
• Due to potential complications ,formalin is used very
rarely.
80

81

EMBOLIZATION
• Therpuetic embolization was described by
Hald in 1984.
• The internal iliac artey was catheterised by
puncturing the femoral or axillary artery
• The internal iliac artery or its anterior division
can be embolized with gel foam.
• The commonest complication is superior
gluteal pain & rarely gangrene of the bladder .
• The success rate is 90 %.
82

HYPERBARIC OXYGEN THERAPY FOR RADIATION
CYSTITIS
• RT causes progressive obliterative endarteritis of
small blood vessels & cause tissue hypoxia.
• Hyperbaric oxygen therapy causes
neovascularisation of bladder wall& increase the
oxygen tension in the bladder.
• 20 session of 100% hyperbaric oxygen inhalation
in .3mPa in a hyperbaric chamber .(each session
90 minutes).
• Decompression sickness may occur rarely.
• Success rate is 75 %.
83

Other therapies
Oral sodium pentosan polysulphate: is useful in
radiation cystitis.
• Dose is 100 mgm three times daily for 3 to 4
weeks .
• It will coat the lining of bladder & increase the
mucosa urine interface.
Intravesical PG are useful in cyclophosphamide
induced cystitis.
84

85

86

87

Prostate related hematuria
• BPH represents most common cause of
prostate related GH. Others are
prostatitis, cancer.
88

89

Urethral bleeding / Urethrorrhagia
• Bleeding from urethra at a point distal to bladder neck,
occuring separate from micturition.
• Retrograde urethrogram and cystourethroscopy are
mainstays for diagnosis in pts with suspected urethral
bleeding.
90

91

Upper urinary tract bleeding
• Cystoscopy at time of bleeding may allow lateralization of
source of hematuria.
• Direct ureteropyeloscopy is recommended as a
diagnostic and potential therapeutic modality in UUT
bleeding.
• Angiography and selective angioembolization is a primary
diagnostic and therapautic option for suspected vascular
conditions causing hematuria.( AVM, ruptured
aneurysms, iliac-ureteral fistulas,nutcracker syndromes.)
92

TRAUMA RELATED HEMATURIA
Degree of hematuria and severity of renal injury are not
corelated.
Criteria for imaging in renal trauma:
all penetrating and decelaration trauma
all blunt trauma with GH
all blunt trauma with MH with shock
all pediatric pts with MH.
93

• Patients with MH without shock can be observed
clinically without imaging studies.
• CECT is gold standard imaging in renal trauma.
94

95

96

FOLLOW UP:
depends upon age and degree of hematuria
1. Adults:
-One episode of gross hematuria and a- ve evaluation
do not need follow up , unless recurred
-Microscopic hematuria: - ve evaluation,
routine follow up with urine analysis ,cytology ,
blood pressure measurements for 3 yrs at 6,12,24
and 36 months
Most recent studies less aggressive or even no follow up, unless
recurrence
2.Children:
-Gross or microscopic hematuria ,-ve evaluation ,
annual re-evaluation with urine analysis
for proteinuria &blood pressure measurement
97

CONCLUSION :
The initial evaluation ,investigation &follow up depends upon
whether pt is a child or an adult
*Main concern in children is to distinguish between glomerular
course
*In adult to differentiate between benign & malignant course.
*In children imaging studies should begin with renal &
bladder USG
*In adult urine culture ,CT IVP, cystoscopy and urine cytology
Follow up:
*In children
After initial –ve evaluation follow up should be routine
*In adults not necessary
98

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Hematuria - causes and evaluation

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