approach to hematuria

1. DR. IMRUL HASAN
MD Resident (Gastroenterology)
BIRDEM General Hospital

2. APPROACH TO HEMATURIA

3. OVERVIEW
• INTRODUCTION
• TRANSIENT HEMATURIA
• SIGNIFICANT HEMATURIA
• CLASSIFICATION
• CLINICAL ASSESSMENT
• INVESTIGATION
• MANAGEMENT
• TAKE HOME MESSAGES

4. Hematuria is blood in the urine and is either visible (macroscopic
,frank or gross) or non-visible(microscopic)
Ref; kumar and clark 24th edition
INTRODUCTON

5. TRANSIENT HAEMATURIA
• Common problem in adults
• Causes:
Exercise
Menstruation
Sexual activity
Viral illnesses
(Ref: Oxford handbook of nephrology & Hypertension)

6.  > 3 RBCs/HPF on three urinalyses or
 A single urinalysis with > 100 RBCs or
 Gross Haematuria
Ref: Harrison’s Principles of Internal Medicine)
PERSISTENT OR SIGNIFICANT HAEMATURIA

7. •According to visibility:
Visible/ Macroscopic haematuria
Non-visible/ Microscopic haematuria
•According to Origin:
Glomerular
Non-glomerular
Ref: Oxford handbook of nephrology & Hypertension
CLASSIFICATION

8. ACCORDING TO VISIBILITY
Macroscopic hematuria:
Visible to naked eye. Gross hematuria startles the
patient so patient presents early .
Microscopic hematuria:
Blood only visible under high power microscopy
Ref:oxford handbook of nephrology and hypertension 2ndedition,p-63

10. ACCORDING TO ORIGIN
Glomerular and Non-glomerular:
Both can present with macro or microscopic bleeding .
Always assume bleeding is non-glomerular (particularly age>
40) until investigation proven.
Ref: Davidson’s Principles & Practice of Medicine

11. IMPORTANT CAUSES OF HEMATURIA
GLOMERULAR NON GLUMERULAR
IgANephropathy Renal stone
Thin basement membrane disease Pyelonephritis
Alport’s syndrome PCKD
Focal GN (eg. Post streptococcal) Papilary nacrosis
Urethral stricture & hydronephrosis
Renal TB
Renal vein thrombosis,renal infraction
Renal trauma
Cystitis,prostitis,urethritis
Bladder,prostate & renal cell carcinoma
BPH
Ref:oxford hand book of nephrology

12. Ref: davidson

13. CAUSES OF PAINFUL & PAINLESS HEMATURA
PAINFUL HAEMATURIA
Infection
Stone
Trauma
PKD
Loin pain haematuria syndrome
Hemorrhagic cystitis due cyclophosphamide
Ref:Davidson 24th edition,oxford hand book of nephrology.
PAINLESS HEMTURIA
Glomerulonephritis ,commonly IgA
nephropathy
Renal tuberculosis
Tumors of urinary system
Bleeding disorder or anticoagulant
therapy
Interstitial nephritis

14. CLINICAL ASSESMENT OF HEMATURIA
• History-
•How much bleeding? Urine discoloured or frankly blood?
• Recent trauma?
•Any previous episodes?
•History of stone disease?
•Relevent medications?
•Recent instrumentation of urinary tract?
•Associated urinary symptoms? Urinary infection?
•Pain:
Sudden onset, colicky flank pain – Stone
Suprapubic pain – Infection,clot colic
Painless macroscopic haematuria – Tumor until proved otherwise

15. CONT.
•In which part of the stream:
-Initial – Anterior urethral lesion
-Terminal – Posterior urethra, bladder, bladder neck,trigone
-Continuous – At or above level of bladder
-Cyclical in female – Endometriosis of urinary tract
•Hematuria after 2-3 weeks of recent skin or throat infection —Post streptococcal GN
•Haematuria 2-3 days afterrespiratorytractinfection – IgA nephropathy
•Systemic symptoms eg.Arthralgia, rashes suggestive of inflammatory disorder
•Family history of deafness (Alport’s syndrome) or other renal
disease?

16. CONT.
Physical examination :
•Haemodynamic stability of the patient.
•Anaemia.
•Any bruising/ bleeding.
•Skin or throat infections — (Post-infectious GN).
•Rashes, swollen joints — (Inflammatory condition e.g.
vasculitis).
•Cardiorespiratory:
—Stigmata of endocarditis.
—BP and oedema - (Glomerular disease).
Abdomen:
-- Flank tenderness (stone disease, pyelonephritis)
-- Masses
-- Bruit (AVM)

17. INVESTIGATION
Urine R/M/E, Phase contrast microscopy , Urine C/S
Urine cytology: malignant cell, casts, dysmorphic red cells
24 hour UTP,ACR,PCR
FBC,BT,CT
Blood sugar
S creatinine, blood urea ,S electrolytes
Imaging: plain x-ray KUB, USG KUB, IVU
(CT with and without contrast, is the investigation of choice.)
 Angiography (rarely)- May demonstrate a vascular lesion.
 Anti GBM antibody, ANA, Anti dsDNA, ANCAs, complement, HBsAg, AntiHCV,
 Anti HIV
 Renal biopsy
Ref: Oxford handbook of nephrology & Hypertension

18. (Ref: Davidson’sPrinciples & Practice of Medicine)

19. (Ref: Davidson’s Principles & Practice of Medicine)
Remember: false positive dipstick occur in haemoglobinuria &
myoglobinuria.
False negative is unusal. So negative dipstick reliably excludes
hematuria

20. MANAGEMENT
• According to cause
• Reassurance & Follow-up
• Supportive treatment: Diuretics, fluid restriction, Anti
hypertensives,Correction of metabolic abnormalities
• Monitoring - BP, I/O, Weight
• ESRD: Dialysis, Renal transplantation

21. TAKE HOME MESSAGE
1. Routine examination of urine sediment should be a must in clinical
practise during evaluating a patient with urinary symptoms or during a
routine check-up to prevent unnecessary & costly investigation & to
detect early stages of renal system disease.
2. Haematuria+ proteinuria is usually suggestive of glomerular disease.
3. Painless macroscopic haematuria is tumor until proved otherwise.