Hematuria is defined as the presence of blood or red blood cells in the urine. It can be macroscopic (visible to the naked eye) or microscopic. Common causes include urinary tract infections, kidney diseases, cancers, and stones. A urinalysis and urine culture can help identify infection, while imaging tests like ultrasound, CT, and cystoscopy can locate any abnormalities in the kidneys, ureters, bladder, or urethra. Further blood tests may also indicate underlying conditions. Hematuria is investigated through examination of urine and imaging of the urinary tract to diagnose the cause.

1. Hematuria
The presence of blood/RBCs in the
urine
Dr. Prajwal Ghimire
Origin:[hemato- [G. haima (haimat-)]+ G. ouron, urine]

2. Causes

3. Definition
• Macroscopic hematuria:
– A substantial haemorrhage into the urinary tract that will give the
urine a red or brownish tinge
• Microscopic hematuria :
– >5 RBCs/hpf on two microscopic urinalyses
• Significant microscopic hematuria:
– On microscopic examination of the urine, >5 RBCs /hpf in spun urine
or >2 RBCs /hpf in unspun urine

4. Haematuria
• Painful or painless
• Gross (visible to the naked eye) or microscopic
• Initial (only at the start of the stream)
• Terminal (only at the end of the stream)
• Total
• intermittent or persistent
• Glomerular or non- glomerular (essential)

5. • Clots present
• Haemospermia (blood also in the semen)
• false
• Egyptian /Endemic: schistosomiasis hematobium
• Renal
• Vesical
• urethral

6. • Blood appearing at the beginning of the urinary stream
indicates a lower urinary tract cause, whereas uniform
staining throughout the stream points to a cause higher up.
• Terminal haematuria is typical of severe bladder irritation
caused stone or infection.
• If the patient experiences pain with haematuria, the
characteristics of the pain may help to identify the source of
the bleeding.
• If there is a malignant cause for the haematuria there is usually
no pain.

7. Investigations for assessment of urinary tract
A. Urinalysis
1.Dipsticks pH, glucose, protein, blood, bilirubin, Useful screening test for diabetes,
ketones, nitrates renal and hepatic disease
2.Microscopy RBCs, WBCs, crystals, bacteria May indicate infection or renal
and gram stain disease
3.Urine culture Number and type of bacteria Diagnosis of UTI
B. Blood analysis Hb, platelets, WBCs May detect anemia/polycythemia
Urea, creatinine, electrolytes Raised in patients with renal failure
Ca++, phosphates, uric acid, albumin Screening for metabolic disorders
in renal calculi
PSA, AFP, HCG Tumor markers for prostatic ca and
testicular ca

8. C. Imaging
1. Structure KUB Detect bony metastases, paget’s
disease, soft tissue masses, abnormal
calcification
IVU Delineates entire urinary tract
USG Assessment of renal and scrotal
masses and bladder emptying
Transrectal USG Useful in assessing prostatic disease
CECT Preoperative staging of renal
carcinoma
2. Function Radioisotope renography Assess function of each kidney
DTPA-99mTc-dimercaptosuccinic acid, independently
DMSA-diethylenetriamine pentaacetic acid.
D. Urodynamics Urine flow rates Useful is assessing degree of
obstruction to micturition e.g.:BPH
Cystometry (static and ambulant) Differentiates between urge and
stress incontinence
E. Endoscopy Cystoscopy Assessment of urinary tract for
Ureteroscopy neoplastic or stone disease
Ureterorenoscopy

9. Differential Diagnosis of red urine
• Hematuria
• Hemoglobinuria/myoglobinuria
• Anthrocyanin in beets and blackberries
• Chronic lead and mercury poisoning
• Phenolphthalein (in bowel evacuants)
• Phenothiazines (e.g., Compazine)
• Rifampin

10. Glomerular hematuria

11. • The urinalysis in nonglomerular medical and
surgical hematuria is similar in that both are
characterized by
– circular erythrocytes and
– the absence of erythrocyte casts

12. An algorithm for the evaluation of
essential hematuria

14. • Is always abnormal whether microscopic or
macroscopic
■ May be caused by a lesion anywhere in the urinary
tract
■ Is investigated by:
• examination of midstream specimen for infection
• cytological examination of a urine specimen
• intravenous urogram and/or urinary tract ultrasound
scan
• flexible or rigid cystoscopy
• Is commonly caused by urinary infection, especially in
young women