Hematuria Work-up and causes Theodore T. Chang, MD Capital Region Urology, Albany Gross/Frank vs. Microscopic • Looking for same causes, but with different degree of urgency • Gross hematuria (even once) needs to be worked up unless obvious source • Examples of obvious sources: • UTI – need to have positive urine culture • or Foley trauma • In both cases, follow-up urine should be clear Hematuria now more common • More hematuria these days with: – Increased use of blood thinners. • Warfarin, Plavix, Lovenox, Integrelin, etc. – Aging population means more BPH and bladder cancer. Differential Diagnosis for Hematuria by Category • Malignant: Bladder, prostate, kidney, penile, urethral. • Infectious: Kidney, prostate, bladder. • Benign iatrogenic: catheter trauma, radiation cystitis, stricture. • Other benign: Stones, BPH, medical renal (parenchymal) disease, papillary necrosis, AVM, exercise, trauma. Differential Diagnosis for Hematuria by Organ System • Kidneys: Kidney and urothelial cancer, stones, pyelonephritis, papillary necrosis, medical renal disease, AVM, exercise, trauma. • Ureters: Stones, urothelial cancer, polyps • Bladder: Urothelial cancer, stones, acute cystitis, radiation cystitis, squamous and adenoca • Prostate: BPH, prostate cancer, prostatitis • Urethra: diverticulum, urothelial ca, stricture, trauma • Penile: squamous cell cancer Gross hematuria • 24 yo man w/Gross Hematuria Plus Flank Pain = Gross hematuria • Gross Hematuria Plus Flank Pain = stones – But also pyelonephritis, papillary necrosis, urothelial cancer, clot colic from kidney cancer. Gross hematuria 45yo man w/Painless Gross hematuria = Gross hematuria Painless gross hematuria = Bladder cancer until proven otherwise Especially with smoking history Especially with irritative voiding symptoms Gross Hematuria • 63yo woman w/Gross hematuria & irritative symptoms Gross Hematuria • 63yo woman w/Gross hematuria & irritative symptoms. • Treated with antibiotics with improvement • Urine culture positive for E. Coli Gross Hematuria • 63yo woman w/Gross hematuria & irritative symptoms. • Treated with antibiotics with improvement • Urine culture positive for E. Coli • Symptoms recur and again better with antibiotics Gross Hematuria • 63yo woman w/Gross hematuria & irritative symptoms. • Treated with antibiotics with improvement • Urine culture positive for E. Coli • Symptoms recur and again better with antibiotics • Symptoms recur and again better with antibiotics • 6 months later, now losing weight Gross hematuria • Bladder cancer with bilateral ureteral obstruction and lung metastases. • March 15, 2001 • Asymptomatic Microscopic Hematuria in Adults: Summary of the American Urologic Association (AUA) Best Practice Policy Recommendations Asymptomatic Microhematuria • No major organization has recommended routine screening for microscopic hematuria • The recommended definition of microscopic hematuria is three or more red blood cells per high-power microscopic field in urinary sediment from two of three properly collected urinalysis specimens. • i.e. urinary sediment from a freshly voided, clean-catch, midstream urine specimen Microscopic Hematuria • Hematuria found on urine dipstick needs to be confirmed by microscopic urinalysis • Urine dipsticks are notoriously inaccurate for hematuria • False positives occur easily if dipstick left out too long before reading, if dipstick container cap is not closed properly, or specimen is collected improperly (typically see epithelial cells on microscopy representing skin contamination) Microscopic Hematuria • Risk Factors for Significant Disease in Patients with Microscopic Hematuria • Smoking history • Occupational exposure to chemicals or dyes (benzenes or aromatic amines) • History of gross hematuria • Age >40 years • History of urologic disorder or disease • History of irritative voiding symptoms • History of urinary tract infection • Analgesic abuse • History of pelvic irradiation • Grossfeld GD, Wolf JS, Litwin MS, Hricak H, Shuler CL, Agerter DC, Carroll P. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy recommendations. Part II: patient evaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation, and follow-up. Urology 2001;57(4) Microscopic Hematuria • Typical work-up is: • History and Physical Upper urinary tract imaging – Ultrasound – CT – IVU Cystoscopy to visualize lower urinary tract (bladder and urethra) Urine cytology (very high positive predictive value, very low sensitivity) Those who need Nephrology work-up • Microscopic urinalysis has red blood cell casts and/or dysmorphic red blood cells • Elevated serum creatinine • Microscopic hematuria plus large amounts of proteinuria (1g/24hr) • May still need imaging, cystoscopy and cytology depending on risk factors Computed Tomography Best modality for evaluation of urinary stones, renal and perirenal infections, and tumors Sensitivity of 94% to 98% for detection of renal stones, compared with 52% to 59% for intravenous urography and 19% for ultrasonography Downside is radiation exposure and expense Need non-contrast for stones and contrast for masses Ultrasound • Good screening tool for masses and hydronephrosis • Differentiate between cysts and solid masses • Limited utility in finding small stones • Does not involve contrast or radiation – OK for contrast allergies and poor kidney function Intravenous Urograms • Limited utility these days • Only picks up larger renal masses and cannot differentiate from cysts • Better than ultrasound for stones, but not as good as CT • Requires contrast and radiation • No longer done at some centers Microscopic hematuria follow-up • Recommendation is follow-up for negative work- up is at 6, 12, 24 and 36 months with urinalysis, blood pressure and cytology • Repeat workup if gross hematuria, abnormal cytology or new irritative voiding symptoms • Nephrology to look for medical renal disease if large amount proteinuria or worsening hypertension UTI? - Be careful • Gross hematuria, even once, needs a work-up. They should not just get antibiotics unless culture is positive. • Microscopic hematuria without symptoms should not get antibiotics unless the culture is positive, especially in the era of antibiotic resistance. – Repeat the urinalysis to confirm hematuria Until proven otherwise Take home points • Gross hematuria (even once) needs work-up unless cause is incredibly obvious • Microhematuria is 3 or more RBCs/HPF on 2 of 3 microscopic examinations • Keep in mind risk factors, especially: Smoking history Occupational exposure to chemicals or dyes (benzenes or aromatic amines) Age >40 years History of urologic disorder or disease History of irritative voiding symptoms.