Postgrad Med J 1997; 73: 129-136 © The Fellowship of Postgraduate Medicine, 1997 Classic signs revisited Postgrad Med J: first published as 10.1136/pgmj.73.857.129 on 1 March 1997. Downloaded from Haematuria Summary AG Rockall, APG Newman-Sanders, MA Al-Kutoubi, JA Vale Many serious and potentially trea- table diseases of the urinary tract may have haematuria as their only The finding of haematuria may herald the presence of pathology within the manifestation. However, asymp- urinary tract. Indeed, early detection and investigation may lead to a potential tomatic microscopic haematuria cure of an underlying malignant disease.'-3 Presentation may be with detected by dipstick testing may symptomatic macroscopic haematuria, although patients with asymptomatic be seen in up to 16% of screening microscopic haematuria are commonly identified during health screening populations. The great majority of programmes. There has been considerable debate concerning the optimal such cases will have no sinister investigation pathway to provide a swift diagnosis in those patients most at underlying cause, particularly in risk of a life-threatening illness.4'5 With the advent of the 'fast track' those under 40 years ofage, and so haematuria clinic, the best use of diagnostic services will be required to the schedule of further investiga- prevent swamping with non-urgent cases.6 There are several areas which are tions, some of which may be under debate in the current literature in which there appear to be widely invasive, time-consuming and ex- varying opinions. In this article, we discuss the epidemiology of the underlying pensive, needs to be rationalised. causes of haematuria, screening methods which may help detect a high risk In addition, the increasing popu- group, the imaging modalities available for the investigation of the urinary larity of 'fast track' clinics for the tract, the recommended investigation pathways and the follow-up when no investigation of haematuria en- diagnosis has been made. hances the need for a clear strat- egy of investigation. Analysis of Epidemiology the epidemiology ofasymptomatic haematuria and its causes com- Haematuria is a relatively common finding which has many potential under- bined with a consideration of the lying causes, ranging from the physiological to the life-threatening. The pre- risk-benefit profile of the avail- valence of haematuria on dipstick testing has been studied in several different able investigations, makes it pos- populations such as patients attending hospital as out-patients, in occupational sible to set out an algorithm for health programmes and in a large medical insurance health screening the initial management of this programme, and has been found to range from 2 to 16%.l'7-"l The prevalence common finding. ofhaematuria when using urine microscopy lies between 1 and 5%.',2,8,'2,'3 The Careful clinicial assessment and range varies depending on the definition of significant haematuria. basic laboratory tests for renal function, analysis of the urinary COMMON CAUSES OF HAEMATURIA http://pmj.bmj.com/ sediment and cytological exami- Physiological excretion of red blood cells is known to occur at low levels nation ofthe urine are followed by in healthy people.8,'4 Haematuria may result from trauma during sexual ultrasound and plain radiography intercourse or urine may be contaminated during menstruation. Vigorous of the urinary tract. Flexible cy- physical exercise is also known to cause haematuria, although this is a stoscopy under local anaesthetic is diagnosis of exclusion. Pathological causes of haematuria may arise central to the algorithm in pa- anywhere within the renal tract, from the glomerulus down to the distal tients of all ages. The importance urethra. on September 24, 2021 by guest. Protected copyright. of a nephrological opinion and The underlying causes of haematuria were studied by Mariani et al'5 in 1000 consideration of renal biopsy, consecutive adult patients using a definition ofhaematuria as three or more red especially in younger patients with blood cells per high power field (HPF). They found the commonest causes of other evidence of glomerular dis- haematuria to be urethritis/trigonitis (37.7%) and benign prostatic hypertrophy ease, is stressed. The role of (17.5%). This was followed by cystitis and transitional cell carcinoma of the intravenous urography in exclud- bladder (6.5%). The commonest causes and life-threatening diseases of the ing pathology ofthe upper urinary renal tract are given in box 1. tract, especially in patients over In the under 40s, the epidemiology is somewhat different. Jones et al'6 the age of 40, is also considered. investigated 100 men under the age of 40 with confirmed microscopic haematuria, performing excretion urography and cystoscopy on all patients. Keywords: haematuria, epidemiology, di- The patients were followed up three months later. Only 32 patients had a agnostic imaging, investigation pathways positive finding (box 2). No diagnosis was made in the remaining 68 patients, although renal biopsy was not performed. There have been reports ofmalignant St Mary's Hospital, London W2 1NY, diagnoses in patients under the age of 40,18 but the incidence rates in the UK are low. Froom et studied 1000 Department of Radiology population very a18 retrospectively asympto- AG Rockall matic air force personnel between the ages of 18 - 33 years. After an average of APG Newman-Sanders 12 yearly examinations, a cumulative incidence of two to four or more red MA Al-Kutoubi blood cells per HPF on at least one examination was reported as 38.7%, with a Department of Urology point prevalence of 5.2%. Of 161 cases with recurrent asymptomatic JA Vale haematuria, only selected cases were investigated. Of these, six had renal one to Dr MA Al-Kutoubi calculi, had a bladder calculus and another had urethritis. A single case of a Correspondence bladder neoplasm was detected over 15 years and in this case there had been an Accepted 29 March 1996 episode of macroscopic haematuria. 130 Rockall, Newman-Sanders, Al-Kutoubi, Vale MALIGNANCY OF THE URINARY TRACT Common and life- The three commonest cancers of the tract are causes of urinary prostatic (in men), threatening Postgrad Med J: first published as 10.1136/pgmj.73.857.129 on 1 March 1997. Downloaded from microscopic haematuria in bladder and kidney.'7 In 1989, 23% of all cancers registered in men were in 1000 adults (from'5) this group and 4.6% of all cancers registered in women (table). Prostatic adenocarcinoma is now the most common genitourinary cancer and the * urethritis/trigonitis 377 incidence rates are increasing rapidly, partly due to increased detection of * benign prostatic hypertrophy 175 the disease. Malignancy of the renal tract is rare in patients under the age of * cystitis (including cystitis cystica) 40. 73 * transitional cell carcinoma of the bladder 65 GLOMERULAR DISEASE * renal and bladder calculi 42 There is a considerable percentage of cases of unexplained haematuria * bladder neck varicosities 33 following urological investigations.16"'8 In studies which actively included renal * glomerulonephritis 12 biopsy in cases of unexplained haematuria, a high percentage have been found * adenocarcinoma of the prostate 10 to have glomerular disease. In one study, Chen et aP9 found that, in a group of * renal cell carcinoma 10 Asian * transitional cell carcinoma of the military recruits with asymptomatic haematuria aged 17-25 years, 54% renal pelvis 5 had glomerular disease. Topham et aP0 found glomerular disease in 47% of 165 * transitional cell carcinoma of the patients with asymptomatic haematuria, with the highest frequency in the ureter 2 younger age groups. IgA nephropathy (Berger's disease), thin membrane nephropathy and global or segmental mesangial proliferative nephritis are the Box 1 commonest glomerular causes of haematuria. Early diagnosis of IgA disease permits monitoring of renal function and control of hypertension which may improve clinical outcome. Commonest causes of microscopic haematuria in Screening for haematuria 100 men under the age of 40 (from16) Screening for haematuria is now an integral part of the routine health checks carried out by general practitioners or at insurance medical examinations. · urethritis/prostatitis 10% Dipstick testing ofurine is a simple, readily available and inexpensive method of · exercise haematuria 7% detection of blood in the urine. This · intrameatal papilloma 3% practice will hopefully lead to the early · friable trigonal vessels 2% detection of pathology with an improvement in prognosis. However, dipstick · urethral stricture 2% testing is known to have a false positive rate of 9-15%,21-23 as they are very · bladder neck stenosis 1% sensitive and indeed may detect physiological amounts of blood in the urine. · urinary tract infection 1% Traditionally, a positive dipstick has been followed up by microscopic · glandular hypospadias 1% examination of the sediment and culture. This has several · idiopathic hypercalciuria 1% urinary benefits, * baggy PC system 1% including the detection of infection or red cell casts. However, haematuria is · duplex system 1% known to be an intermittent phenomenon and the level of haematuria has not · ureteric calculus 1% been found to relate to the risk ofserious underlying disease.1 Thus, it has been · trigonal cystitis cystica 1% suggested that a single positive dipstick should be fully investigated.3,22'24 · no diagnosis made 68% Opinions vary, however, and in the search for a distinguishing feature of a high-risk group, age has been recommended.8,'6 Patients over the age of40 have http://pmj.bmj.com/ Box 2 a greater risk of malignant disease and should have access to urgent and full investigation. In the under 40s, less invasive tests should be used to rule out simple diagnoses such as urethritis or a urinary tract infection prior to embarking on more invasive tests. Table Registrations of urinary tract malignancy in 1989 (percentage of History and examination total cancer registrations)17 on September 24, 2021 by guest. Protected copyright.