Armando Hasudungan
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Haematuria

Haematuria is a common symptom with a multitude of differentials. Common urological causes of haematuria include urinary tract infection and ureteric and renal stones, but concurrent pathology should be suspected if haematuria is significant or persistent. Importantly, if benign conditions are excluded, and the haematuria continues, further investigation is advised, as this may be the only sign of an underlying genitourinary malignancy.

Overview Haematuria is defined as evidence of blood in the urine under microscopy. It is a common symptom of both benign and malignant conditions.

  • Haematuria can be microscopic or macroscopic (visible red/brown urine).
  • Haematuria can be symptomatic or asymptomatic
  • Haematuria can be glomerular or non-glomerular
Common causes Features
UTI Dysuria, fever, fatigue, nausea/vomiting
Nephrolithiasis (Renal stones) Renal colic, flank pain radiating to back
Malignancy Painless macroscopic haematuria
Post interventional Recent catheterization or other procedures
Glomerulonephritis Depends if nephrotic or nephritis syndrome
Vasculitis Microscopic haematuria, often asymptomatic
Remember Transient haematuria: Exercise (‘joggers’ nephritis’), Menstruation, Sexual activity, UTI, Viral illnesses and Trauma.
Definition
Haemturia: Blood in urine
Microcopic (Invisible) haematuria:
Macroscopic (Visible) haematuria:
Dysuria: Pain while urinating

Approach Establish is it symptomatic or asymptomatic, microscopic or macroscopic and is it perhaps glomerular or non-glomerular (look at GFR, renal history)?

  • History
    • Urinary symptoms
    • What part of the stream?
      • Throughout – upper urinary tract cause
      • Start or finish – lower urinary tract cause
    • Risk factors for malignancy
  • Examination – Check every system
    • Joint inflammation, rash → autoimmune
    • Signs of anaemia
    • ↑BP and Oedema → glomerular disease
    • Flank pain/tenderness → stones, pyelonephritis
  • Investigation
    • Exclude transient causes
    • Urine dipstick
    • EUC
Remember >40 year old presenting with haematuria is bladder malignancy (+/- risk factors) until proven otherwise

Investigation aims to confirm your diagnosis and or rule out other differential diagnosis. Investigations should help confirm whether it is glomerular or non-glomerular.

  • Clinical Examination – Check prostate on PR exam
    • PSA?
  • Full blood count – Infection and Anaemia
  • EUC – Kidney function
  • eGFR – Glomerular or non-glomerular?
  • Urine dipstick
  • Urine MCS
  • Urine Cytology
  • Group and hold – for blood loss incase you need to resuscitate
  • Ultrasound Kidney – to identify renal tumours or cysts
  • Cystoscopy (gold standard) –  Identify bladder tumour and other urinary tract malignancies
  • CT scan abdomen – Renal tumour suspected
Remember Initial investigations for haematuria should include intravenous pyelogram, urine cytology, full blood examination, renal function, and PSA in men.

Differential Diagnosis

Hematuria

Differential Diagnosis of Haematuria


Microscopic invisible haematuria In Australia, microscopic haematuria is defined as >10 red blood cells in high field power on microscopic evaluation. This varies from >3–10 cells depending on British, European or American definitions. Microscopic haematuria should be confirmed by repeating the urine microscopy so that at least two of three tests are positive. Most common causes include UTI, BPH and renal stones. However, 70% of microscopic haematuria causes are unknown, and is thought to be attributed to transient benign physiological conditions, including vigorous physical exercise, sexual intercourse or menstrual contamination. Assess risk of urological malignancy

DIFFERENTIAL DIAGNOSIS OF MICROSCOPIC (INVISIBLE) HAEMATURIA
Condition History Examination
UTI Dysuria, fever, fatigue, nausea/vomiting Fever, suprapubic tenderness
Benign prostatic Hyperplasia Nocturia, polyuria, hesitancy, uregency, double voiding Enlarged prostate on digital rectal examination, palpable bladder due to urinary retention
Nephrolithiasis (Renal stones) Sudden onset renal colic, flank pain radiating to back, nausea, vomiting Renal angle tenderness
Polycystic Kidney Disease Family History Bilateral Kidney enlargement
Glomerulonephritis High Blood pressure, weight gain, oedema,
Menstruation Cyclical haematuria associated with menstruation
Prostatitis Pelvic pain, dysuria Digital rectal exam – tender prostate
Urethral strictures
Post interventional Recent catheterization or other procedures Presence of catheter or urethral stent
Trauma (post sex, exercise) Recent sexual activity, strenuous exercise  –
Vasculitis Microscopic haematuria, often asymptomatic
Rhabdomyolysis Recent fall/trauma Myoglobin present not haemoglobin. But myoglobin is still picked up on dipstick

 

Remember 70% of microscopic haematuria causes are unknown
GLOMERULAR DISEASE
Likely Unlikely
Haematuria throughout voiding Haematuria initial or terminal voiding
Proteinuria Fever, night sweats and sudden weight loss
Oedema, oliguria, dark urine
High BP Blood clots
Joint ache, rash
Dysmorphic RBCs and RBC casts

Macroscopic (Visible) Haematuria is more concerning and warrants thorough investigation, as the prevalence of urinary tract carcinomas among patients with macroscopic haematuria are quite high (~5-20%). However, 50% of microscopic haematuria causes are unknown, and is thought to be attributed to transient benign physiological conditions, including vigorous physical exercise, sexual intercourse or menstrual contamination. Assess risk of urological malignancy

DIFFERENTIAL DIAGNOSIS OF MACROSCOPIC (VISIBLE) HAEMATURIA
Condition History Examination
UTI Dysuria, fever, fatigue, nausea/vomiting Fever, suprapubic tenderness
Nephrolithiasis (Renal stones) Sudden onset renal colic, flank pain radiating to back, nausea, vomiting Renal angle tenderness
Benign Prostatic Hyperplasia Nocturia, polyuria, hesitancy, urgency, double voiding Enlarged prostate on digital rectal examination, palpable bladder due to urinary retention
Bladder Cancer Painless macroscopic haematuria
Prostate cancer Advanced age, weight loss, night sweats, decreased appetite. Urinary symptoms Abnormal digital rectal examination, prostate nodule or diffuse hardness of the gland
Alport’s Syndrome
(Connective tissue disease)
Hearing impairment, family history of haematuria, hearing loss, or renal disease Hypertension, oedema, sensorineuronal hearing loss, anterior lenticonus, corneal erosions
Post interventional Recent catheterization or other procedures Presence of catheter or urethral stent

Referral

Urologist Referral is recommended in patients presenting with macroscopic haematuria, persistent microscopic haematuria, abnormal urine cytology, irritative lower urinary tract symptoms or recurrent urinary tract infections.

  • >40yo
  • Risk factors for malignancy
  • Macroscopic haematuria
  • Upper urinary tract imaging abnormality
    • Ultrasound
    • CT
    • Intravenous urography
  • Lower urinary tract assessment abnormality
    • Urine Cytology

Nephrologist Referral

  • Systemic signs and symptoms
  • Glomerular disease suspected?
  • Low eGFR
  • Abnormal EUC

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