A detailed approach to hematuria in a step by step manner for undergraduate students of MBBS with clinical cases for better understanding the topic of hematuria. Starting from hematuria definition causes of hematuria,glomerular vs non glomerular causes,isolated hematuria,hematuria innewborn,myoglobinuria,not all red is hematuria ending with crisp approach

1. Dr. Kaviayarasi muthamizhan
Final yr MBBS
Government thiruvannamalai medical college
Thiruvannamalai

2. DEFINITIONS
 GROSS /MACROSCOPIC HEMATURIA :
visible to the naked eye
 MICROSCOPIC HEMATURIA :
>5 RBCs/HPF in centrifuged sample
 TRANSIENT HEMATURIA:
usually microscopic and benign
fever, infections ,trauma and exercise
 PERSISTENT HEMATURIA:
Persistent finding of hematuria in atleast two or three
urinalyses performed over 2-3 weeks

3. CLINICAL TERMINOLOGIES FOR
PRESENTATION OF HEMATURIA
Gross
hematuria
Single
episode
recurrent
Microscopic
hematuria
isolated
With
proteinuria

4. CONFIRMATION OF HEMATURIA
Urine sample
Urine dipstick
Urine
microscopic exn
 urine dipstick identifies hemeprotein
( SENSITIVITY=100% SPECIFICITY – 99% in detecting 1-5
RBCs/HPF )
FALSE POSITIVE FALSE NEGATIVE
Oxidising substances Vitamin C
Alkaline ph >9 formalin

5. DIPSTICK
MICROSCOPY

6. Positive urine dipstick
Urine
microscopy
>5 RBC
HEMATURIA
NO RBC
HEMOGLOBINURIA
MYOGLOBINURIA
PLASMA
COLOR
RED
HEMOGLOBINURIA
CLEAR
MYOGLOBINURIA

7. HEMOGLOBINURIA MYOGLOBINURIA

8. NEGATIVE URINE
DIPSTICK
RBC
HEMOGLOBIN
MYOGLOBIN
But urine
red colour ??
All that is red is not blood
Search for other causes of
red urine

9. SUBSTANCES CAUSING
DISCOLARATION OF URINE
• RED OR PINK URINE
• Urates
• Porphyrins
• Beets,red dyes in food
• Drugs:chloroquine,desf
errioxime,pyridum
• DARK YELLOW/ORANGE
• Normal concentrated
urine
• Rifampicin
• Pyridium
• DARK BROWN/BLACK
• Methemoglobinemia
• metronidazole

10. • Confirmed true hematuria
• Next step???
• LOCALIZATION OF BLEEDING
glomerular vs non glomerular

11. CASE 1
A 7 year old girl presented with
• h/o cola coloured urine 4 days
• Swelling of face & legs -2 days
• Oliguria -2 days
• Breathlessness -1 day
• h/o sore throat 2 weeks back
• O/E edema,BP>99 th percentile,tender hepatomegaly
• Urinalysis appearance : brown
RBC- plenty
albumin- 5to6/hpf

12. CASE 2
• 10 year old boy with
• red coloured urine-2 days
• colicky pain in right flank
• dysuria , increased frequency, urgency,
stranguary
• no oliguria,edema, hypertension
• Urinalysis appearance : bright red
albumin trace
RBC- plenty
WBC 6-10 /HPF

13. FEATURES GLOMERULAR NON GLOMERULAR
HISTORY
Dysuria Absent Present in urethritis and
cystitis
Systemic complaints Edema, fever,
pharyngitis,rash, athralgia
Fever with UTI, pain with
calculi
Family history Deafness, hematuria in
alport syndrome
May be positive with
calculi and hypercalcemia
PHYSICAL EXAMINATION
Hypertension,edema Usually present Less common
Abdominal mass Absent Present in wilms tumor,
obstructive uropathy
Rash, arthritis Lupus erythematosus,
henoch schnolein purpura
Absent (unless drug
induced interstitial
nephritis)

14. URINARY
FINDING
GLOMERULAR
HEMATURIA
NON
GLOMERULAR
HEMATURIA
color Red or brown Usually red
clots absent May be present
proteinuria 2+ or more Less than 2+
RBC
morphology
dysmorphic Eumorphic

15. CASE 1
GLOMERULAR DISEASE
CASE 2
NON GLOMERULAR DISEASE

16. GLOMERULAR DISEASE
• Acute PIGN common
• PSGN
• Ig A nephropathy
• Benign familial
hematuria
• Membranoproliferative
• FSGS
• SLE
• Systemic infections
(malaria,
leptospirosis,infective,
endocarditis)
• HUS
• Henoch schnolein
purpura
• Alport’s syndrome
• Goodpasture’s syndrme

17. MECHANISM
RBC passes through
the damaged
basement
membrane
Morphology of RBC
will be deformable

18. Morphology of RBC is modified by
Intrinsic deformability
Intraglomerular capillary pressure
Size of the gap
Thickness of basement membrane
Variation in urine pH
Osmotic pressure
Effects of tubular enzymes

19. NON GLOMERULAR CAUSES
• UTI common
• Nephrolithiasis
• Hypercalciuria
• Viral haemorrhagic
cystitis
• Vascular abnormalities
• Trauma, tumours,
exercise
• Renal cystic disease
• Tuberculosis
• Munchaussen
syndrome

20. CASE 3
• 8 year old boy presented with
• Red coloured urine : 3 months
• Intermittent once every 2-3 weeks for 2-3 days
• Painless
• No h/o burning micturition, increased frequency
• No h/o periorbital puffiness, edema,
oliguria,hypertension
• Urinalysis: RBC- plenty
WBC:3-4 pus cells
albumin: = +1 albumin
between the episodes normal
RECURRENT HEMATURIA

21. CAUSES OF RECURRENT HEMATURIA
GLOMERULAR CAUSES
• Ig A nephropathy
• Benign familial hematuria
• Alport’s syndrome
NON GLOMERULAR CAUSES
• Nephrolithiasis
• Hypercalciuria
• Tumours
• Sickle cell disease
• tuberculosis

22. MICROSCOPIC HEMATURIA
ISOLATED
WITH PROTEINURIA

23. ISOLATED MICROSCOPIC HEMATURIA
Urinalysis repeated twice within 2 weeks
If on suspected medicine – withold
& recheck …
careful reitertion of history, special
emphasis on family history
RFT, URINE ca:cr ratio, proteinuria, USG,
Hb electrophoresis, coagulation profile ,
test parents for hematuria
negative
negative
negative
positive
positive
Follow every
2-3 months
Identify the cause and treat accordingly

24. MICROSCOPIC HEMATURIA WITH
PROTEINURIA
• PIGN
• Minimal change nephrotic syndrome
• Ig A Nephropathy
• Membranoproliferative GN
• Alport’s syndrome
• Thin BMD
• Focal segmental glomerulosclerosis
• Membranous nephropathy

25. CASE 4
• 7 days old term male baby with
• Red staining of diapers
• No fever, feeding well, good activity
• No significant antenatal history
• Urinalysis : PUS- 10 to 15/hpf
RBC 8-10

26. CAUSES OF HEMATURIA IN THE
NEWBORN
• Renal vein thrombosis
• Renal artery thrombosis
• Autosomal recessive polycystic kidney disease
• Urinary tract infection
• Trauma
• Bladder catheterization

27. HEMATURIA – QUESTIONS TO ASK
Recent sore throat or skin
infection ?
POST STREPTOCOCCAL
GLOMERULONEPHRITIS
Associated fever, dysuria or
flank pain ?
PYELONEPHRITIS
History of high blood pressure
?
NEPHRITIC SYNDROME
Family history of
deafnessrenal disease ?
ALPORT SYNDROME
Chronic medical problems ? SLE, SICKLE CELL ANAEMIA
History of purpuric rash,
abdominal pain?
HENOCH SCHONLEIN PURPURA
History of trauma ? BLEED IN URINARY TRACT

28. APPROACH TO A CHILD WITH
HEMATURIA
Detailed history
Physical
examination
In true
hematuria –
localize bleeding
Glomerular or
non glomerular