Urology

1. EVALUATION AND MANAGEMENT OF
HEMATURIA
CHAIR PERSON: Dr SANJAY R.P
CO CHAIR PERSON: Dr RAJENDRA PRASAD

2. Introduction
Hematuria : Greek words haima (blood) and ouron (urine)
to refer to presence of blood in urine.
Hematuria is defined as the presence of an abnormal
quantity of red blood cells (RBCs) in the urine.
Hematuria has been recognized as a sign of medical
illness since antiquity.
Today, hematuria is one of the most common indications
for urologic evaluation.

3. CLASSIFICATION
A) Based on Intensity:
1 - Microscopic: The presence of >3 RBCs / HPF
2 - Macroscopic or Gross: Urine is red in color. This is a "red
sign" for the patient to ask for medical advice.
B) Based on Origin:
1 - Systemic disease
2 - Urinary tract pathology

4. CLASSIFICATION
C) Based on Relation to micturition:
1 - Total hematuria (MC) is present
all over the voided urine. Underlying
pathology may be in kidney, ureter,
bladder or prostate or systemic.
- Bleeding from kidney is associated
with cylindrical worm-like clots.
- Hematuria from bladder and
prostate is associated with big,
irregular or discoid clots.

5. CLASSIFICATION
2 - Terminal hematuria at the end of micturition is of vesical
origin e.g. active bilharzial cystitis.
- It is usually due to bladder neck or prostatic inflammation.
- It occurs at the end of micturition as the bladder neck
contracts, squeezing out the last amount of urine.
3 - Initial hematuria at the beginning of micturition indicates
urethral pathology.

6. CLASSIFICATION
D) Based on Associated symptoms:
Painless hematuria: No other urinary symptoms.
All cases should be investigated for urologic malignancy.
Bladder cancer is the most common and should be excluded.

7. CLASSIFICATION
Hematuria associated with other symptoms:
- Simple cystitis: frequency, burning, urgency and terminal
hematuria.
- Malignant cystitis: severe frequency, pain, urge
incontinence, total hematuria with clots or necroturia
- Ureteral obstruction due to blood clots is the most common
cause of pain associated with gross hematuria.
- Stones: Renal pain.
- BPH, prostate cancer: associated LUTS (prostatism).
- Surgical trauma to kidney and bladder e.g. PCNL &
TURBT.

8. CLASSIFICATION
E) Based on Etiology:
General or systemic:
Bleeding disorder: thrombocytopenic purpura, leukemia,
hemophilia.
Liver cirrhosis.
Anticoagulants.
Hypertension.

9. CAUSES

10. CAUSES
Renal causes:
A) Nephrologic: dysmorphic RBCs
Acute glomerulonephritis is the most common cause in children
and young adults.
It is associated with proteinuria.
B) Urologic: normo morphic RBCs.
Congenital: Polycystic kidney.
Inflammation: Pyelonephritis, TB.
Trauma: Accidents, Iatrogenic.
Stones
Kidney cancer
Vascular: Hemangiomas, AV fistula.

11. CAUSES
Ureteral:
Stones.
Iatrogenic trauma e.g. ureteroscopy.
Tumors: TCC of pelvis and ureter.
Bladder:
Bladder cancer is the most common cause of gross hematuria
in a patient above 60 years.
Cystitis: Bacterial, bilharzial, T.B.
Stones
Trauma e.g. post TURBT

12. CAUSES
Prostate
BPH
Prostate cancer
Prostatitis
Surgical: after prostatectomy
Posterior urethra
Inflammation
Trauma
Tumor

13. Evaluation

14. Evaluation
Hematuria of any degree should never be ignored.
- In adults, should be regarded as a symptom of urologic
malignancy until proved otherwise.
- In evaluating hematuria, several questions should always
be asked.
- The answers will enable the urologist to target the
subsequent diagnostic evaluation efficiently.

15. Evaluation
1) Is the hematuria gross or microscopic?
2) At what time during urination does the hematuria occur
(beginning or end of stream or during entire stream)?
3) Is the hematuria associated with pain?
4) Is the patient passing clots?
5) If the patient is passing clots, do the clots have a specific
shape?

16. Evaluation
- The significance of gross versus microscopic hematuria is
simply that the chances of identifying significant pathology
increases with the degree of hematuria.
- The patients with gross hematuria usually have identifiable
underlying pathology.
- It is common for patients with minimal degrees of
microscopic hematuria to have a negative urologic
evaluation.

17. Evaluation
- Hematuria, although frightening, is usually not painful unless
it is associated with inflammation or obstruction.
- Thus patients with cystitis and secondary hematuria may
experience painful urinary irritative symptoms.
- Pain in association with hematuria usually results from upper
urinary tract hematuria with obstruction of the ureters with
clots.
- Passage of these clots may be associated with severe,
colicky flank pain similar to that produced by a ureteral
calculus.
- This helps identify the source of the hematuria.

18. Evaluation
- The presence of clots usually indicates a more significant
degree of hematuria.
- Accordingly, the probability of identifying significant
urologic pathology increases.

19. Evaluation
Amorphous : bladder origin or Prostatic urethral origin
Vermiform (wormlike) clots, particularly
 If associated with flank pain,
 Hematuria coming from the upper urinary tract,
 Suggests from within the ureter.

20. Testing

21. Hematuria - dipstick analysis
- Normal - <3 erythrocytes/hpf
- Chemical detection is based on peroxidase like activity of
hemoglobin.
- Degree of colour change is directly related to the amount of
hemoglobin present in the specimen.
- Field colour change : hemoglobin /myoglobin
- Coloured dots : intact erythrocytes undergo hemolysis and localised
free haemoglobin on the pad produces a corresponding dot of colour
change.
- Coalescence - more than 250 erythrocytes/mL.

22. Hematuria-dipstick analysis
- Hemoglobinuria and myoglobinuria by microscopic examination.
- In hemoglobinuria the supernatant will be pink- free haemoglobin in
serum binds to haptoglobin(high molecular weight and water insoluble)
In myoglobinuria the serum remains clear.
- Sensitivity of urinary dipsticks - identifying hematuria 3
erythrocytes/hpf. >90%
- Specificity is lower compared to microscopy making high false
positive rate .

23. Hematuria-dipstick analysis
- False positive results
Women during menstruation,
Significant dehydration
Vigorous exercise
- Normal individual excretes 1000 erythrocytes/mL,
upper limit 5000-8000 erythrocytes/mL.
- High specific gravity - false positive results.
- Efficacy of hematuria screening with dip stick is
controversial.

24. Differential diagnosis and evaluation of hematuria
- Nephrologic vs urologic first step.
- Nephrologic- associated with casts and almost always significant
proteinuria.
- Erythrocyte evaluation also helps to differentiante nephrologic vs
urologic.
- Glomerular- dysmorphic
- Tubulo interstitial disease/ urologic uniformly round shape- ghost
cells.

25. Differential diagnosis and evaluation of hematuria

26. Glomerular hematuria

27. Non glomerular hematuria
Medical vs surgical
Proteinuria
- Medical causes
Tubulointerstitial
Renovascular
Systemic disorders

28. Non glomerular hematuria
Family H/O
1)Hematuria and bleeding tendency- blood dyscrasia.
2)Urolithiasis with intermittent hematuria - inherited stone disease-
serum and urine measurements of calcium and uric acid
3) Renal cystic disease- evaluate for medullary sponge kidney,
ADPKD
- In diabetics , suspected analgesic abusers- papillary necrosis.
- Anticoagulants at normal therapeutic levels doesn’t predispose to
hematuria, unless excessively coagulated.
- Proper thorough work up as non anti coagulated individuals.

29. Non glomerular hematuria
- Exercise induced hematuria - vigorous exercise and long distance
runners(>10km)
Rapidly disappears at rest.
- Renal or bladder
Renal - first sign of glomerular disease like IgA nephropathy
Bladder - cystoscopy punctate haemorrhages are seen.
- Vascular disease
Nut cracker syndrome

30. Non glomerular hematuria
Surgical
Urologic tumors, stones, benign prostatic hyperplasia and UTI.
Essential hematuria is absence of significant proteinuria.
Asymptomatic microscopic hematuria
- >/= 3 RBC’s /hpf (10-20 microscopic fields to be evaluated under
400x magnification)
- Properly collected sample(mid stream, undiluted (308mOsm)
- Absence of an obvious benign cause. (sex/exercise/menstruation/first
sample- repeat)

31. Non glomerular hematuria
Symptomatic microscopic hematuria
- Higher levels of microscopic (>25RBC’s/hpf)
- Gross hematuria
- Risk factors for malignancy
- Higher chances of malignancy detection.

32. Management

33. Microscopic hematuria

34. Microscopic hematuria

35. Definition
- >3 red blood cells per high- power field on microscopic
evaluation of a single, properly collected urine specimen.
- Clinicians should not define microhematuria by positive
dipstick testing alone.
- A positive urine dipstick test (trace blood or greater) should
prompt formal microscopic evaluation of the urine.

36. Initial evaluation
- In patients with microhematuria, should perform a history and
physical examination to assess risk factors for genitourinary
malignancy, medical renal disease, gynecologic and non-malignant
genitourinary causes of microhematuria.
- Should perform the same evaluation of patients with
microhematuria who are taking antiplatelet agents or anticoagulants
as patients not on these agents.

37. Initial evaluation
- In patients with findings suggestive of a gynecologic or non-
malignant urologic etiology, should evaluate the patients with
appropriate physical examination techniques and tests to
identify such an etiology.
- In patients diagnosed with gynecologic or non-malignant
genitourinary sources of microhematuria, clinicians should
repeat urinalysis following resolution of the gynecologic or
non-malignant genitourinary cause.
- If microhematuria persists or the etiology cannot be
identified, clinicians should perform risk-based urologic
evaluation.

38. Initial evaluation
- In patients with hematuria attributed to a urinary tract
infection, should obtain a urinalysis with microscopic
evaluation following treatment to ensure resolution of the
hematuria.
- Clinicians should refer patients with microhematuria for
nephrologic evaluation if medical renal disease is suspected.
However, risk-based urologic evaluation should still be
performed.

39. Risk stratification

40. Risk stratification

41. Evaluation - after risk stratification
Low-Risk
In low-risk patients with microhematuria, clinicians should engage
patients in shared decision-making to decide between repeating
urinalysis within six months or proceeding with cystoscopy and renal
ultrasound.
Initially Low-Risk with Hematuria on Repeat Urinalysis
Low-risk patients who initially elected not to undergo cystoscopy or
upper tract imaging and who are found to have microhematuria on
repeat urine testing should be reclassified as intermediate- or high-
risk.
In such patients, should perform cystoscopy and upper tract imaging
in accordance with recommendations for these risk strata.

42. Evaluation - after risk stratification
Intermediate-Risk
Should perform cystoscopy and renal ultrasound in patients
with microhematuria categorized as intermediate-risk for
malignancy.

43. Evaluation - after risk stratification
High-Risk
- Should perform cystoscopy and axial upper tract imaging in
patients with micro hematuria categorised as high-risk for
malignancy.
- Options for Upper Tract Imaging in High-Risk Patients:
If there are no contraindications to its use, clinicians should perform
multi phasic CT urography
- If there are contraindications to multiphasic CT urography,
clinicians may utilise MR urography.
- If there are contraindications to multiphasic CT urography and MR
urography, clinicians may utilise retrograde pyelography in
conjunction with non-contrast axial imaging or renal ultrasound.

44. Evaluation - after risk stratification
- Clinicians should perform white light cystoscopy in patients
undergoing evaluation of the bladder for microhematuria.
- In patients with persistent or recurrent microhematuria
previously evaluated with renal ultrasound, clinicians may
perform additional imaging of the urinary tract.
- In patients with microhematuria who have a family history of
renal cell carcinoma or a known genetic renal tumor
syndrome, clinicians should perform upper tract imaging
regardless of risk category.

45. Gross Hematuria
- Macroscopic haematuria is more concerning and warrants
thorough investigation.
- The prevalence of urinary tract carcinomas among patients
with macroscopic haematuria has been reported to be as
high as 19%, but usually ranges from 3–6%.

46. Evaluation

47. Ultrasound

48. Cystoscopy

49. Management
- Most episodes of haematuria will settle conservatively with
no acute intervention required.
- A smaller percentage with more significant haematuria
including -
- a high risk of clot retention,
- haemodynamic instability,
- a drop in haemoglobin,
- cardiovascular symptoms
will require hospital admission for continuous bladder irrigation
and management of symptomatic anaemia.

50. Management
- The most common acute emergency presentation of
haematuria is acute urinary retention secondary to blood clots
(clot retention).
This typically presents with acute abdominal pain and an
inability to urinate.
- In these cases, patients will also need catheter insertion and
continuous irrigation. Blood transfusions may also be required.
- In severe cases, patients may require emergency cystoscopy
and diathermy if they are not responding to conservative
management.
it is also important to determine and treat the underlying cause.

51. Hemorrhagic cystitis
- Intractable hematuria localizing to the bladder, or
hemorrhagic cystitis, may range in severity from a transient
condition that quickly resolves after conservative management
to a life-threatening condition requiring urgent intervention.
- Hemorrhagic cystitis is characterized by diffuse inflammation
and bleeding from the bladder mucosa.

52. Causes:

53. Management :

54. - Alum (aluminum ammonium sulfate or aluminum potassium
sulfate) may be dissolved in sterile water.
(50 g alum in a 5-L bag of sterile water [1% alum solution])
and then used to irrigate the bladder at a rate of 200 to 300
mL/h .
- Alum may cause protein precipitation on the urothelial lining
and thereby stimulate vasoconstriction and a decrease in
capillary permeability.

55. - HBOT is carried out in a specially designed chamber and
involves administration of 100% oxygen at a pressure of 2 to 3
atmospheres for approximately 90 minutes in 30 to 40
sessions.
- Local tissue oxygen tension increases and thus oxygen
extraction by tissues increases, thereby diminishing edema
and promoting neovascularization, all of which are critical
steps in the wound healing process.

56. - Formalin, a solution of formaldehyde that induces cellular
protein precipitation and capillary occlusion may be used.
- Intravesical formalin therapy - complications,
including bladder fibrosis with associated decreased bladder
capacity and ureteral stricturing with proximal
hydronephrosis/renal injury.
- Thus pretreatment cystogram is recommended to exclude the
presence of vesicoureteral reflux and/or bladder perforation.
- Given the potential toxicities of formalin, together with the
requirement for administration under anesthesia, this agent
should be reserved for second-line therapy.

57. Hematuria of Prostatic origin
- Hematuria from prostatic origin is a diagnosis made after a
complete GH evaluation to confirm that no other source of
hematuria exists.
- From transient self-limiting episodes to continuous bleeding
resulting in the obstruction of urinary flow.
Most commonly, prostate-related bleeding is due to
- BPH,
- prostate-related infection (prostatitis), or
- prostate cancer.

59. Urethral bleeding
- Urethral bleeding (urethrorrhagia) is defined as bleeding
emanating from the urethra at a point distal to the bladder
neck, occurring separate from micturition.
- Careful history and physical examination may help elucidate
whether the source of bleeding is truly from the urethra as
opposed to other sites within the lower urinary tract.
- Blood at the urethral meatus in the absence of volitional
micturition, initial hematuria, implies pathological processes
distal to the external urinary sphincter.

61. - In men, trauma to the urethral epithelium represents the
most common cause of urethral bleeding.
- Perineal or penile bruising, accompanied by a hematoma,
often is a clear indication of injury related to trauma.
- Retrograde urethrography is essential in instances of trauma
when a urethral injury is suspected.
- History of foreign body insertion in patients with hematuria
may necessitate imaging and/or cystoscopy to ensure no
residual foreign elements.

62. - Particular mention should be made to the evaluation of
bloody urethral discharge and/or hematuria occurring in
patients with a penile fracture.
- In this setting, prompt evaluation via retrograde
urethrography or cystoscopy should be undertaken to
evaluate for a urethral injury and to identify the nature and
location of the injury before surgical exploration.

63. - Urethritis refers to infection or inflammation of the epithelial
lining of the urethra.

64. Lateralising essential hematuria
- Lateralizing essential hematuria, also termed benign essential
hematuria or chronic unilateral essential hematuria,
is defined as macroscopic hematuria cystoscopically localized
to one side of the urinary system without a clear identifiable
cause.
- Cystoscopy at the time of bleeding may allow lateralization of
the source of hematuria.
- In the absence of a clear cause for bleeding localized to the
upper tract, direct endoscopic inspection with
ureteropyeloscopy is recommended as a diagnostic and
potentially therapeutic modality.