This document discusses hematuria, or the presence of red blood cells in urine. It defines gross hematuria as visible red or brown urine, and microscopic hematuria as 3 or more red blood cells per high-powered field in urine samples. The causes, patterns, and workup of hematuria are described. Transient microscopic hematuria is common and often does not require extensive evaluation unless the patient is over 50 or has other risk factors. Evaluation of persistent hematuria may involve urine analysis, cystoscopy, imaging tests, and renal biopsy depending on findings.

1. Dr. Hamed Ezzat El-Eraky
Nephrology Specialist
Mansoura International Hospital
Hematuria

2. Haematuria
It is the presence of RBC in urine
 Gross haematuria
Suggested by the presence of red or
brown urine.
 Microscopic haematuria
Defined by the AUA Panel > 3 RBCs
/HPF in 2 out of 3 properly collected
Urine (fresh centrifuged mid stream

3. Pattern of haematuria
 Time:
Initial  urethral
Terminal  prostate or bladder
Total  renal, bladder or ureter
 Gross or microscopic
 Painful or painless
 Symptomatic or asymptomatic

4. False +ve test
Haemoglobinuria
Myoglobinuria
Ascorbic acid
False –ve test
Highly diluted urine

5. DD of red or brown urine.
Not all red urine is hematuria
Haematuria
Myoglobinuria  rhabdomyolysis +ve
dipsticks
Heamoglobulinuria  heamolysis.
Drugs: Nitrophorantion., rifampicine, Ibuprofen,
Desferoxamine, Chloroquine
Food dyes: Beet, blackberries, food coloring
Metabolites: Bile pigments, Porphoria, Urate
crystals

7. Causes of hematuria

12. Transient or persistent
 Repeat the urine analysis within few
days to evaluate if transient or
persistent.
 Causes of transient hematuria:
1. Fever
2. Infection
3. Trauma
4. Exercise
5. Consider malignancy in old patient
with transient hematuria.

13. •Up to 40% of adults have microscopic
haematuria at least once
•16% have 2 or more attacks during life
•So extensive work up only indicated in the
following:
•Age above 50 years
•Presence of other clinical disorders
Transient Microscopic
Haematuria

14. Exercise induced hematuria:
 Microscopic or gross hematuria can occur
after exercise.
 It is common after football, boxing, direct
trauma to the kidney and long distance
running.
 DD of exercise induced gross hematuria is
march hemoglobulinuria, myoglobulinuria
due to rhabdomyolysis.

15. Historical clues
Concurrent pyria, dysuria UTI
Recent upper resp tract inf. Postinf-GN, IgA.
+ve FH of renal dis. APCKD, herd.nephritis
Renal colic Ureteral calculous obst.
prostatic Symptom SEP, prostatic cancer
Vigorous exercise Exercise induced
Bleeding disorder
Oliguria, HTN, proteinuria, edema glomerulonephritis
Cyclic bleeding Endometriosis
Sickle cell trait in blacks Pap necrosis, hematuria

16. Unexplained hematuria
 The term unexplained hematuria is
defined if no diagnosis from history,
urinalysis, radiologic tests or
cystoscopy.

17. Causes of unexplained
hematuria
 Mild GN: mostly IgA, thin BM dis.
 Predisposition to stone as hypercalciuria,
hyperurecosuria.
 A-V malformation and fistula.
 Loin pain hematuria syndrome.
 Undiagnosed carcinoma of UT.

18. Follow-up OF idiopathic
microscopic hematuria
highriskgroup
• Repeat urinalysis
every 6 months
• Repeat urine
cytology every 6
months
• Repeat cystoscopy
every year
Lowriskgroup
usually followed
with periodic
urinalyses and
urine cytology

19. SCREENING
NO recommendation
for screening of
asymptomatic
hematuria
the prevalence
of undetected,
asymptomatic,
hematuria <2
%
little evidence
that hematuria
is a sensitive
test for
localized
disease
is little
evidence that
ttt results in a
better
prognosis

20. Extraglomerular versus
glomerular.

21. Indication of renal biopsy
• isolated heamaturia, since there is no
specific therapy to any of these
condition.
Biopsy is
not usually
indicated
• progressive disease:
• Increased creatinine
• Increased protein excretion,
• unexplained rise in BP even when
these values is within normal.
Biopsy
should
considered

22. Approach of red urine
RBC
morphology
Non- Glomerular
Surgical
haematuria
Glomerular
Medical
haematuria

23. Work-up ended
Urine dipstick test +ve for microscopic
hematuria
Repeated urine dipstick test several
days later
Workup ended unless there is risk
factors-ve
+v
e
Microscopical examination of urine -ve Evaluation for
hemoglobulinuria or
myoglobulinuria
RBCs cast, dysmorphic
RBCs
Isomorphic RBCs
Glomerular hematuria
Nonglomerular hematuria
Isolated microscopic
hematuria
Isolated microscopic
hematuriaperiodic medical
follow up
For onset of proteinuria or
renal insufficiency
Proteinuria and renal
insufficiency
Helical CT +ve
Referral
acc to
lesion-
ve
cytologic analysis of urine (3
serial 1st morning sample) +ve
cystoscop
y
nephrology
referral
>50ys , risk factor for
bladder cancer
<50ys , without risk factor for
bladder cancer