NMGH Weekly Meeting

1. Urology & Nephrology Center, Mansoura University,
HAEMATURIA
By
Mohamad A. Sobh, MD, FACP
Prof. of Nephrology
Urology & Nephrology Center
Mansoura University
Egypt

2. Urology & Nephrology Center, Mansoura University,
Definitions:
Normally the number of RBCs in urine
should not be more than 5 RBCs/ high
power field on microscopic examination
of fresh centrifuged urine sample.
So, haematuria is defined as a secretion of
more than 5 RBCs/ HPF in urine.
Haematuria

3. Urology & Nephrology Center, Mansoura University,
Transient microscopic haematuria is
relatively common. Up to 40% of adults
between ages of 18 and 33 may have
microscopic haematuria at least once, and
up to 16% may have it in two or more
occasions.
Therefore, an extensive workup is not
indicated except in high-risk patients, > 50
years of age and those patients with other
clinical or urinary abnormalities.

4. Urology & Nephrology Center, Mansoura University,
Initial is usually urethral.
Terminal hematuria is usually prostatic or
bladder origen.
Total hematuria is either bladder, ureteral
or renal origen.
Gross or Microscopic.
Painfull or painless.
Symptomatic or Asymptomatic.
Patterns Of Haematuria

5. Urology & Nephrology Center, Mansoura University,
Transient haematuria
• Exercise ( ‘ joggers ’ nephritis ’ ).
• Menstruation..
• Viral illnesses.
• Trauma

6. Urology & Nephrology Center, Mansoura University,
In gross hematuria, urine looks red if alkaline,
but brown or coca-cola like if urine is acidic
due to denaturation of the hemoglobin.

7. Urology & Nephrology Center, Mansoura University,
False positive test for haematuria:
 Haemoglobinuria.
 Myoglobinuria.
 Ascorbic acid.
False negative test for hematuria:
 Highly diluted urine.

8. Urology & Nephrology Center, Mansoura University,
Differential Diagnosis of Haematuria:
A- First, haematuria should be differentiated from
other causes of red or brownish urine:
 Haemoglobinuria (haemolysis)
 Myoglobinuria (muscle damage)
 Porphyrins (in porphyria)
 Bile (in jaundice)
 Melanin (in melanoma)
 Alkaptonuria,
 Food dyes.
 Drugs as PAS or phenylphthalein.

9. Urology & Nephrology Center, Mansoura University,
Dipsticks (Hemastix) will be positive
with haematuria, haemoglobinuria and
with myoglobinuria but negative with
other causes e.g. porphyrins bile
melanin, alkaptonuria, food dyes and
drugs as PAS or phenylphthalein.
Microscopy will show RBC’s only
with haematuria.

10. Urology & Nephrology Center, Mansoura University,
B-Haematuria could be glomerular (because of
glomerular disease, sometimes called medical); or
non glomerular (sometimes called surgical).
Glomerular haematuria could be differentiated
from non glomerular haematuria by:
1. The shape of RBCs in urine are small and
dysmorphic in cases with glomerular haematuria
while it will be normal in case of non glomerular
haematuria.

11. Urology & Nephrology Center, Mansoura University,
2. Proteinuria is present in most cases of
glomerular hematuria but not in cases of non
glomerular hematuria.
3. Casts, especially red cell casts are seen in
glomerular haematuria.
4. Blood clots indicate non-glomerular bleeding
and can be associated with pain & colic.

12. Urology & Nephrology Center, Mansoura University,
(in dipsticks test reaction occurs between orthotolidine and
haemoglobin or myoglobin).

13. Urology & Nephrology Center, Mansoura University,

14. Urology & Nephrology Center, Mansoura University,
Causes of Haematuria
I. Haematuria of renal origin:
 Glomerular haematuria
 Renal infection and tubulointerstitial diseases.
 Renal neoplastic diseases:
 Hereditary renal diseases
 Coagulation defect
 Stone disease.
 Renal vascular disease
 Exertional haematuria.
II. Haematuria of ureteral origin:
III. Haematuria of bladder origin:
IV. Haematuria of urethral origin.

15. Urology & Nephrology Center, Mansoura University,
Haematuria of renal origin:
a.Glomerular haematuria: Either primary
glomerular disease (e.g. IgA nephropathy,
mesangial proliferative
glomerulonephritis or crescentic
glomerulonephritis); or secondary
glomerulonephritis i.e. renal
involvement is a part of systemic
disease (e.g.post-strephococcal
glomerulonephritis, Henoch-Schönlein
purpura, SLE, polyarteritis nodosa).

16. Urology & Nephrology Center, Mansoura University,

17. Urology & Nephrology Center, Mansoura University,

18. Urology & Nephrology Center, Mansoura University,

19. Urology & Nephrology Center, Mansoura University,

20. Urology & Nephrology Center, Mansoura University,
b.Renal infection and tubulointerstitial
diseases: Pyelonephritis, renal papillary
necrosis, tuberculosis, and toxic
nephropathies.
c.Stone disease.
d.Renal neoplastic diseases: Renal cell
carcinoma, transitional cell carcinoma of
the renal pelvis and others.
e.Hereditary renal diseases: Medularly,
sponge kidney, polycystic kidney disease,
Alport’s syndrome, and thin basement
membrane disease.

21. Urology & Nephrology Center, Mansoura University,
f. Coagulation defect: use of
anticoagulant, liver disease and
thrombocytopaenia.
g. Renal vascular disease: Renal
infarction, renal vein thrombosis or
malignant hypertension.
h. Exertional haematuria.

22. Urology & Nephrology Center, Mansoura University,

23. Urology & Nephrology Center, Mansoura University,

24. Urology & Nephrology Center, Mansoura University,

25. Urology & Nephrology Center, Mansoura University,

26. Urology & Nephrology Center, Mansoura University,

27. Urology & Nephrology Center, Mansoura University,
II. Haematuria of ureteral origin:
a. Malignancy.
b. Nephrolithiasis.
c. Ureteral inflammatory condition
secondary to nearby inflammation
e.g. diverticulitis, appendicitis or
salpingitis.
d. Ureteral trauma e.g. during
ureteroscopy.
e. Ureteral varices, aneurysms, or
arteriovenous malformation.

28. Urology & Nephrology Center, Mansoura University,
III. Haematuria of bladder origin:
a. Infection: schistosoma, viral or bacterial
cystitis.
b. Neoplasma.
c. Foreign body in the bladder e.g.
stones.
d. Trauma: During instrumentation or
accidental.
e. Drug: e.g. cyclophosphamide induced
haemorrhagic cystitis.

29. Urology & Nephrology Center, Mansoura University,
Cyclical haematuria in ♀ suggests
endometriosis of the urinary tract

30. Urology & Nephrology Center, Mansoura University,
IV. Hematuria of urethral (or
associated structures) origen:
a. Urethritis, foreign body or
local trauma to the urethra.
b. Prostate: Acute prostatitis,
benign prostatic hypertrophy.

31. Urology & Nephrology Center, Mansoura University,
1. First exclude haemoglobinuria and
myoglobinuria since both of them can
also cause positive dipstick test for
haematuria. This is done by microscopic
examination of fresh urine sample. In case
of haematuria, RBCs could be seen while
in the other two conditions no RBC’s could
be seen.
Investigations of a case of
haematuria

32. Urology & Nephrology Center, Mansoura University,
In case of myoglobinuria, clinical
examination may show manifestations of
muscle disease and the examination of
urine by immunoelectrophoresis may show
myoglobin.
In case of haemoglobinuria, manifestations
of haemolysis may be evident

33. Urology & Nephrology Center, Mansoura University,
2. Examination of urine for:
 Proteinuria.
 Casts.
 Pus.
 Bacteria (specific and non specific)
 Culture (Ordinary and special)
 PCR (TB-DNA)

34. Urology & Nephrology Center, Mansoura University,
3. Ultasound, plain X-ray, I.V.P. (if
serum creatinine is normal), and
possibly angiography, for the
diagnosis of surgical diseases e.g.
stone, malignancy, infection, or
malformations.

35. Urology & Nephrology Center, Mansoura University,
4. RBCs in urine could be examined for its
shape to differentiate glomerular (small,
distorted) from non glomerular causes
(by phase contrast microscopy).
5. Kidney function tests.
6. Specific investigations for diagnosis of
systemic disease causing haematuria
e.g. SLE.
7. Kidney biopsy for glomerular
haematuria.

36. Urology & Nephrology Center, Mansoura University,
Microscopic haematuria and the risk of ESRD
• A recent longitudinal study of 1.2 million young individuals
(aged 16 – 25) presenting for military service found an initial 0.3%
prevalence of persistent microscopic haematuria (with normal SCr and
proteinuria <200mg/day).
• Males were affected twice as commonly as females.
• During 21 years ’ follow-up, ESRD developed in 0.7% of those with (and
0.045% of those without) initial microscopic haematuria.
• This gave an adjusted hazard ratio of 18.5.
• The mean age of ESRD treatment was earlier (34 vs 38) in the haematuria
cohort and attributed mainly to glomerular disease.
• While the relevant advisory bodies do not presently advocate population
screening, these recent data have led to a call for selected screening of
younger patients so that they can be followed up more closely for the
development of overt renal disease.
* Vivante A, Afek A, Frenkel-Nir Y, et al . (2011). Persistent asymptomatic
isolated microscopic hematuria in adolescents and young adults and risk for
end-stage renal disease. JAMA .

37. Urology & Nephrology Center, Mansoura University,
1. Treatment of the cause.
2. Haemostatic e.g.:
 Cyclokapron.
 Vitamin K
 DDAVP
 Frish frozen plasma.
3. Haematenics and blood transfusion.
Treatment Of Haematuria

38. Urology & Nephrology Center, Mansoura University,