Hematuria is defined as the presence of red blood cells in urine. It can be classified as gross or microscopic based on visibility. Hematuria requires investigation to identify underlying causes like malignancy, stones, or renal disease. Evaluation involves history, exam, urinalysis, imaging, and potentially biopsy. Treatment depends on the identified cause, which may include surgery, chemotherapy, or monitoring for progressive disease. Differential diagnosis considers non-blood substances that can appear red in urine. The epidemiology of hematuria depends on demographics and the primary disease process causing red urine.

1. HAEMATURIA
BY DR TIMOTHY.M

2. Definition
 Hematuria is defined as the presence of 3-5 or more
red blood cells (RBCs) per high-power field in 3 of
3 consecutive centrifuged specimens obtained at
least 1 week apart
 Hematuria is a sign and itself is not a disease.
 Identification points towards a potential risk of an clinically significant
pathology, such as malignancy, urolithiasis or medical renal disease,
trauma, drugs such as anticoagulants
 Therefore, hematuria ALWAYS requires investigation to rule out an
underlying cause

3. Types
 According to the amount of RBC in the urine, hematuria can be
classified as:
1. Gross haematuria-Haematuria observable through direct visual inspection of the urine. Color may be pink
,red brown, tea-colored urine(Often symptomatic)
2. Microscopic haematuria-Only detectable by microscopic examination of the urine(e.g.>3-5RBC/HPF-must
have at least 2 separate urine (Often asymptomatic)
Distinction between the two is important because the former is most likely due to cancer
 According to Timing (when it occurs during urination):
1. Early (initial) Haematuria: Urethral origin, distal to external
Sphincter, prostate
2. Terminal Haematuria: Bladder neck or prostate origin eg bladder neck schistomsomiasis
3. Diffuse (total) Haematuria: Source is in the bladder or upper
urinary tract( ureter, kidneys)

5. Types Continued
 Haematuria can be painful or painless
 Painful –Kidney + ureters
 Painless-Bladder ,urethra ,prostate
 Management-Begins with History/Examination
Indentify cause and any associated complication

6. Aetiology
 Diseases of the urinary system – the
most common cause
1. Glomerular
2. Interstitial
3. Uroepithelium
4. Vascular

7. Pathophysiology
 Haematuria can be :
 Glomerular
 Non glomerular
Distinction between glomerular and non-glomerular hematuria is important towards diagnosis of
cause:
 Glomerular hematuria: Brown-colored urine, RBC casts, and dysmorphic (small, deformed
,misshapen ,sometimes fragmented) RBCs and proteinuria
 Nonglomerular hematuria: Reddish or pink urine, passage of blood clots, and
eumorphic (normal-sized, biconcavely shaped)RBCs

8. Glomerular and Non-gromerular

9. History
 Recent urological intervention-bladder catheterization, indwelling catheter
stent ,recent prostate biopsy
 Trauma to the bladder, ureter ,kidneys, urethra
 Tumors
 Glomerulonephritis-infection, toxins, drugs ,diabetes, HTN, Autoimmune
mechanism
 Nephrolithiasis/urolithiaisis- eg at the pelviureteric junction ,pelvic brim,
vesicoureteral junction
 Any coagulopathies

10. History
Question Why
Recent sore throat or skin infection Post-strep glomerulonephritis
Associated fever ,dysuria, flank pain
,frequency
UTI, pyelonephritis
History of high Blood pressure Nephritic syndrome and renal involvement
History of purpuric rash, abdominal pain Henoch –Schoenlein purpura
Recent trauma to the abdomen Hydronephrosis .urethral injury
Early morning periorbital puffiness, weight
gain, oliguria, dark-colored urine and
edema
Glomerular cause(causes painless
Haematuria)
Joint pain, skin rashes, prolonged fever A collagen vascular disorder(Rheumatoid
arthritis,SLE)

11. History
 Information regarding exercise, menstruation, recent bladder
catheterization, intake of certain drugs or toxic substances, or
passage of a calculus may also assist in the differential
diagnosis
 Haematuria + proteinuria=glomerular disease

12. Physical Examination
 Measurement of the blood pressure and volume
status is especially important when glomerulonephritis is a
consideration.
 Evaluation for the presence of periorbital puffiness or peripheral
edema
 Detailed skin examination to look for purpura.
 Abdominal examination to look for palpable mass reveals a
renal tumor or hydronephrosis may exist,
 A palpable bladder after voiding indicates obstruction or
retention

13. Physical Examination Continued
 A bruit over the kidney suggests a vascular cause.
NB Always check for extrarenal manifestations and co morbid
conditions.
 PR examination – to rule out prostatitis, prostate cancer, epididymitis,
meatal stenosis, and other structural causes of hematuria .
 Inspect external genitalia in male for trauma.
 Atrial fibrillation raises the possibility of renal embolic infarction,
especially if the patient has flank pain
 Costovertebral angle tenderness is also suggestive of
pyelonephritis, nephrolithiasis, or ureteropelvic junction obstruction

14. Diagnosis
 The laboratory tests ordered for the evaluation of hematuria must be
based on the clinical history and the physical examination.
 Tests that
may be helpful include the following:
1. Urine dip stick urine for blood is the urine test strip or dipstick, which utilizes the
peroxidase-like activity of hemoglobin to generate a color change. False-positive tests
may occur in the setting of myoglobinuria or
hemoglobinuria, confirmed by the absence of RBCs on microscopic
examination.
2. Urinalysis with careful microscopic review of the urine sample
4.

15. Diagnosis Continued
 Hematological-UECs ,LFTs
 Urine culture for suspected urinary tract infection (UTI)
 Serologic testing: Measuring serum complement levels if suspect glomerular cause. E.g. a high
antistreptolysin (ASO) titer suggests a recent streptococcal infection. Antinuclear antibody (ANA)
titers and the measurement of double-stranded DNA (dsDNA) levels are most helpful in children
with suspected systemic lupus erythematosus nephritis.

16. Diagnosis Continued
 PSA Assay
 Urinary bladder CA markers
 Kidney Biopsy
 Rarely indicated. Only if:
1. significant proteinuria
2. Abnormal renal function
3. Recurrent persistent hematuria
4. Serologic abnormalities (abnormal complement, ANA, or dsDNA
levels)
5. Recurrent gross hematuria
6. A family history of end-stage renal disease

17. Imaging Studies
 The following may be helpful:
a) Renal and bladder ultrasonography
b) CT urography
c) MRI.
d) IVU
e) Cystoscopy

18. Management
 Urine drainage
 Irrigation
 Iv line
 IV Fluids
 FHG,GXM

19. Treatment
 Treatment depends on cause
 In conditions associated with abnormal clinical ,laboratory, or imaging studies, treatment
may be necessary, as appropriate, with the primary diagnosis
 Surgical intervention may be necessary with certain anatomic
abnormalities (eg, ureteropelvic junction obstruction, tumor, or
significant urolithiasis) eg TCC-surgery
chemotherapy /radiotherapy
 Outcome-depends on the cause
 Patients with persistent microscopic hematuria should be monitored every 6-12 months for
the appearance of signs or symptoms indicative of progressive renal disease

20. Differential Diagnosis
 Not everything in urine is blood
1. Rhabdomyolysis food(Beetroot, blackberries)
2. Urate crystals(in infants)
3. Hemoglobinuria
4. Drugs(rifampin ,pyridium)
5. Dyes(anilinine dye in candles)
6. Metabolites(porphyrias,bilirubin ,tyrosinemia)abnormal
 Polluted urine: menstruation
 Drug and food: Rifampicin, Nitrofurantoin, sulfonamides, adriamycin.
 Porphyria: porphyrin in urine (+)
 Hemoglobinuria (hemolysis)
 Myoglobinuria

21. Epidemiology
 Since hematuria is the end result of various processes, the morbidity or mortality is
dependent on the primary cause
 Incidence in specific race is also determined by the primary cause e.g. sickle cell disease
hematuria is more common in blacks than whites
 Sex also predisposes a child to specific diseases that manifest as hematuria e.g. sex-
linked Alport syndrome has a male preponderance whereas lupus nephritis is commoner
in adolescent girls
 Wilms tumor commoner in preschool children, also acute post-infectious
glomerulonephritis
 In Adults, malignancies of the GUT such as RCC, bladder Ca or prostate ca are common
primary causes

22. THANK YOU