This document discusses hematuria, or blood in the urine. It defines macroscopic and microscopic hematuria and describes how hematuria can be classified. Common causes of hematuria are discussed, including stones, infections, tumors, trauma, vascular issues, anatomical anomalies, and inherited conditions. Evaluation of hematuria involves urine analysis, urine culture, imaging like ultrasound or CT, and possible cystoscopy. Follow up is usually needed due to risk of underlying malignancy. Four case examples are presented.

1. HEMATURIA
Mostafa Magdi Eltawel
Associate professor
Urology

2. Hematuria
Transient phenomenon
of little significance
Sign of serious
renal disease

3. Definition
• Macroscopic (gross) Hematuria
• any discolored urine visible to the human eye
• Microscopic Hematuria
• >3-5 RBC/hpf seen under microscope

4. Classification of
hematuria
Macroscopic - Microscopic
Symptomatic - Symptomless
Transient - Persistent
According to the act of void:
-Initial.
-Terminal.
-Total.

5. • 25% of patients with gross hematuria have a
life threatening urologic lesion
• 5 to 20% of patients with microscopic
hematuria may have a serious urologic
disorder
• 1% of patients may develop a neoplasm even
though an initial workup is negative within 3-4
years
• Up to 18% of normal individuals may have
some degree of microscopic hematuria

6. DETECTION OF HEMATURIA
• Dipstick testing 91% sensitivity, 65% specificity for
the detection of Hgb
• False positives caused by:
• Myoglobinuria
• Menstrual bleeding
• Dehydration (increased SG level)
• Outdated or dried dipsticks
• Substances or medications

7. Substances and medications
• Artificial food coloring
• Beets
• Berries
• Lead or mercury poisoning
• Meds: adriamycin, chloroquine, hydroxychloroquine,
metronidazole, nitrofurantoin, phenazapyridine,
rifampin

8. Most common causes
• S stones
• I infection
• T tumor
• T trauma

9. Etiology of Hematuria
• V vascular
• I infectious
• T Tumor/ trauma
• A anatomic anomaly
• M metabolic
• I inherited
• N nonspecific

10. Vascular
• Aneursym
• Renal vein thrombosis/ Infarct
• Malignant hypertension
• nephritis

11. Infectious
• Bacterial (remember levaquin)
• Viral
• Fungal
• Parasitic
• TB

12. Tumor/ trauma
• Kidney, ureteral, bladder, prostate, urethral
malignancy
• Instrumentation
• Radiation
• Exercise
• Foreign body
• Trauma

13. Anatomic anomaly
• BPH benign prostatic hyperplasia
• Pelvic muscle relaxation
• Renal duplication
• UPJ obstruction
• Polycystic kidney
• Medullary sponge kidney
• Strictures
• Ureterocele or urethrocele

14. Metabolic
• Kidney stones
• Bladder stones
• Drug induced

15. Inherited
• IgA nephropathy (Berger’s disease)
• Sickle cell anemia
• Benign familial hematuria

16. Nonspecific
• Physiologic
• Exercise
• Fever
False Positive
- Endometriosis
- Vaginal bleeding
- factitious

17. History
• Gross vs. microscopic
• Initial, terminal, or throughout stream
• Painful, irritation, or flank pain
• Recent strep or skin infection
• Medications
• Smoking, occupational exposure
• Trauma/ instrumentation, radiation/ chemo

18. Physical exam
• Vital signs
• Rashes, petechiae, mottling
• Flank or abdominal mass
• Genitalia exam

19. Lab studies
• UA
• UA C&S
• If indicated: CBC, PT/PTT/ INR

20. Radiological
• KUB
• U/S
• C.T
• MRU

21. Glomerular versus extra glomerular bleeding
Urinary finding Glomerular Extraglomerular
Red cell casts May be present Absent
Red cell
morphology
Dysmorphic Uniform
Proteinuria May be present Absent
Clots Absent May be present
Color May be red or
brown
May be red

39. Urology referral
If not previously evaluated for hematuria, ALL
patients need a cystoscopic examination of the
bladder mucosa. NO radiologic study or urinary test
(cytology, NMP-22, or BTA-stat) fully evaluates the
bladder.

40. Nephrology referral
• Significant proteinuria without hematuria
• RBC casts
• Elevated creatinine above 2.5

41. Follow up
• Somewhat controversial
• Repeat UA, cytology every 6 months for 2 years
followed by yearly exams.
• Re-evaluation for a new episode of gross hematuria
if over 6 months and no previous cause was found.
• 18% of patients may always have hematuria without
a definitive cause

42. Case 1
• A 65-year-old woman is referred with total painless
haematuria. A midstream specimen of urine (MSU)
has been sent for microscopy, culture and sensitivity.
Microscopy shows a normal white cell count (WCC),
over count red blood cells (RBCs) per high-powered
field and no growth has been found on culture. She
has moderate irritative voiding lower urinary tract
symptoms (LUTS).The patient also gave a history of
anorexia, weight loss, and night sweating . No other
investigations have been performed. How would you
assess this woman?

43. CASE 2
• A 35-year-old man presents to the emergency
department with intermittent right loin to groin pain
and visible hematuria. He had history of passing
stones . What is the likely cause?

44. CASE 3
• Male patient 55 years old , diabetic , hypertensive ,
and heavy smoker , presented to you with red
discoloration of urine . The patient gave a history of
taking anti ischemic drugs due to recent myocardial
infarction one month ago, what is the most probably
cause of hematuria , and how to exclude a urological
cause ?!

45. CASE 4
• A 64-year-old man presents with a 2-month history
of painless visible haematuria, hypertension, weight
loss, loin swelling and anaemia. What is the most
likely diagnosis?