Hematuria - A Diagnostic Approach

Douglas Stahura D.O.

GVH

8/24/00

Goals

• Epidemiology

• Evaluation

• Differential Diagnosis

• Case Reports

Hematuria - Epidemiology• Definitions

– Macroscopic - pink, red, or tea colored– Microscopic - >4 RBC’s per hpf of spun

urine sediment

• Prevalence– School aged - 4% (always check a 2nd

specimen)– >35 y/o - 13%– PPV low, most useful in elderly men

Hematuria - Epidemiology

• Specific– Glomerular causes -

– Predominate in children and young adults– >40 y/o only 5% of cases

– Neoplasm– >40 y/o, Urinary tract 15-20% of cases– Children: Wilm’s tumor,

Rhabdomyosarcoma of bladder

Hematuria - Evaluation

• History

• Physical

• Urinalysis

Hematuria - Evaluation

Hematuria - Evaluation• Urinalysis

– Proteinuria - indicator of glomerular disease

• can be up to 500 mg/24 hr in gross hematuria

– RBC cast - must look at urine with your own eyes

– Pyuria - look for UTI/STD– Crystals– Dysmorphic RBC’s

Hematuria - Evaluation

• Glomerular Dx– Renal bx– C3,C4, CH50– ASO, ANA,

cryoglobulin– ANCA, anti-GBM– SPEP/UPEP, Ig– audio/eye– sickle screen

• Non-glomerular Dx– culture– Chlamydia, N.

gonorrhea– renal U/S– Flat plate Abd– IVP– Cystoscopy

Hematuria - Cases

• Case 1– 22 y/o WF gross hematuria x2 days– mother of 2: 4y/o, 4mo– works 12 hr shift as waitress, 3 in 4 d– monagamous x 2 years– +/- dysuria, +/- flank pain– PE - no trauma– UA - pro 2+, WBC 5-10/hpf, Bac 1+

Hematuria - Cases

• Case 2– 65 y/o WM gross hematuria x6 weeks– denies pain, freq, hesitancy– 50 pack-yr cigarette– PE - unremarkable– UA - Pro 2+, WBC none, Bac none

Hematuria - Cases

• Case 3– 44 y/o male gross hematuria and episodic

flank pain radiating to groin on left side. Unable to find comfortable position.

– PE - uncomfortable, distressed, restless– UA - gross hematuria

Hematuria - Cases

• Case 4– 75 y/o male with microscopic hematuria on

screening. Hx of hesitancy and weakened urinary stream.

– PE - 150/85, enlarged prostate without nodularity/tenderness

– UA - 8-10 RBC’s/hpf

Hematuria - Cases

• Case 5– 41 y/o male with 2 episodes of gross

hematuria over last 24 hours.– Completed AF marathon yesterday– PE - unremarkable– UA - 15-20 RBC’s/hpf

Hematuria - Cases• Case 6

– 52 y/o female with 4 day hx of upper respiratory sx of cough, fever, scant sputum production.

– Over 24h, progresses to Acute respiratory failure

– PE - on vent, febrile, normotensive, oliguric, bloody sputum, anemic.

– UA - microscopic hematuria, + Legionella antigen, occ dysmorphic RBC’s, BUN/Cr = 54/5.5 CXR - B/L patchy infiltrates

Hematuria - Cases• Case 7

– 39 y/o male construction worker presents to ED with L arm swelling and tenderness. Denies trauma. + warmth/erythema x4d

– Teated with Keflex x 7d. – 10 d post ATBX, notices blood in urine– PE - L arm nl, 150/85, NAD– UA - 5-10 RBC/hpf, occ dysmorphic rbc, no

casts, bac, WBC reported.

Hematuria - Cases• Case 8

– 20 y/o Japanese exchange student presents with URI sx x1 day. Cough, low grade fever, headache, myalgias. On day two, notices blood in urine.

– PE - t=99.2, cough, no sputum, minimal distress.

– UA - RBC TNTC, Pro 4+, no casts, no bac.