1596 ANTICOAGULANT ASSOCIATED HEMATURIA

ticoagulants in which no life threatening urological lesions were found when only a single urinalysis with a low red blood cell count per high power field was present. The episode of hema- turia may be the only clue to a significant uropathologid condition, which is particularly germane to malignancies of the genitourinary tract (which tend to present in more advanced stages). Although patients with anticoagulant associated hema- turia tend to have more cardiovascular disease and be older,” the evaluation for microscopic or gross hematuria is fairly be- nign, has a high yield for detection of a genitourinary etiology and leads to a greater than 90% rate of resolution of hematuria ifthe patient el& treatment. Thus, we recommend a complete urological evaluation for all patients with nontraumatic antico- agulant associated hematuria. Our finding of significant uro- logical disease in 30% of the patients on anticoagulant therapy with prothrombin or partial thromboplastin times in the ther- apeutic range raises the interesting possibility of using antico- agulants to facilitate the detection of urological disease.

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9. Maier, U. and Bergmann, M.: Hamaturie unter Antikoagulan- tientherapie als Symptom urologischer Erkrankungen. Uro- loge, 19: 165, 1980.

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11. Kaufman, S. A. and McLellan, P.: Urinary tract complications of anticoagulation therapy; “pseudotumour“ of the kidney. Brit. J . Urol., 41: 180, 1968.

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EDITORIAL COMMENT

The authors should be congratulated on their attempt to address, in an organized fashion, an important clinical problem to urologists and primary care physicians alike, that is when to evaluate patients receiving anticoagulation therapy for hematuria. In general, their findings support those of others who have reported similar yields for evaluating hematuria in adults who are and are not receiving anti- coagulation (reference 5 in article).lS2 Approximately 80% of middle- aged and elderly men with even asymptomatic microscopic hematu- ria (whether or not they are receiving anticoagulation therapy) will have an etiology determined from a standard urological evaluation. Roughly a third will have a cause detected that requires therapy, and a third of these will have malignancy as the underlying culprit (references 5 and 13 in article).’ However, as the authors acknowl- edge, while they have included all patients referred to their clinic, this series does not by any means represent all individuals receiving anticoagulants who have hematuria. Instead, it consists of those who have been selected by the primary care physicians to undergo uro- logical evaluation. Thus, the guidelines proposed for evaluating he- maturia in patients receiving anticoagulation (all patients with more than 5 red cells per high power field on even a single urinalysis and repetitive positive urinalyses for those with less than 5 red cells per high power field) are not substantiated in the data they present. The question that the authors could not address but that is critical in the current health care delivery climate of increasing managed care, limiting referrals to specialists and keeping an eye on cost contain- ment is whether individuals with a single episode of microscopic hematuria while receiving anticoagulation and who are asymptom- atic need to undergo evaluation. However, since 30% of the 10 asymptomatic patients had a significant pathological condition and since half of those with microscopic hematuria only had conditions requiring treatment, primary care physicians and urologists who may otherwise be reluctant to evaluate individuals receiving antico- agulation therapy without symptoms and/or “only” with microscopic hematuria should be reminded that it is difficult to determine which patient could safely forego evaluation without having a significant pathological condition overlooked.

The authors are also correct in pointing out that hematuria in the patient receiving anticoagulation requires special considerations, including often repeating radiographic studies to determine if upper tract bleeding resolves, and using multidisciplined approaches to withholding anticoagulation during evaluations and episodes in which significant or life threatening hemorrhage occurs. Finally, while not expressly noted in this article, it must be remembered that conditions that cause hematuria but usually need no treatment (for example, asymptomatic, nonobstructing peripheral caliceal calculi) may require therapy in the patient who must remain on anticoagu- lants indefinitely.

Edward Messing Division of Urology University of Wisconsin School of Medicine Madison, Wisconsin

1. Messing, E. M., Young, T. B., Hunt, V. B., Rust, P. and Wehbie, J. M.: Urinary tract cancers found by home screening with hematuria dipsticks in healthy men over 50 years of age. Cancer, 64: 2361, 1989.

2. Messing, E. M., Young, T. B., Hunt, V. B., Emoto, S. E. and Wehbie, J.: The significance of asymptomatic microhematuria in men age fiRy and over: findings of a homescreening study using urinary dipsticks. J . Urol., 137: 919, 1987.