Hematuria

Definition
Passage of RBC in the urine. We have to distinguish it from other causes of
urine discoloration, because red urine is not always caused by hematuria.
If hematuria has initially been diagnosed on dipstick, it must always be
confirmed by microscopy.

DD Hematuria
Microscopic hematuria : From at least 2 properly collected urine
specimen show >3 RBC/hpf. Transient (UTI), strenuous (exercise),
spurious (contamination from menstruation and sexual course),
persistent (true hematuria).
Macroscopic hematuria : Red brown urine, sometimes with blood clot.
Always pathologic.

Or

Renal
Glomerular
o IgA nephropathy
o Alport disease and thin basement membrane nephropathy
o Glomerulonephritis
Non Glomerular
o Neoplastic (RCC, benign renal mass)
o Tubulointerstitial (nephrolithiasis, PKD, pyelonephritis, AIN)
o Vascular (arterial/ vein thrombosis, Nutcracker syndrome,
malignant hypertension)
o Metabolic (hypercalciuria/ uricosuria)

Extrarenal
Ureter (mass, stone, stricture)
Bladder (Transitional cell carcinoma, cystitis)
Urethra (urethritis, traumatic catheterization, stricture)
Prostate (BPH, prostatitis, cancer)

Some drugs that can cause red urine

Rifampin
Chloroquin
Ibuprofen
Nitrofurantoin
Phenytoin
History Taking
Pain associated with infection/ inflammation
Painless associated with tumor or TB
Loin pain Kidney disease
Colic pain stone
Suprapubic pain + dysuria + frequency cystitis
Initial hematuria suggest bleeding from urethra and prostate
Terminal hematuria prostate and bladder
Total hematuria Upper urinary tract
History of familial polycystic kidney dz, TB
Travelling schistosomiasis
History of catheterization
Check for prostatism

Pelvic injury and fracture

Medication anticoagulant, other drugs
Any history of blood malignancies, malaria and sickle cell disease, hemolysis
Strenuous exercise, muscle injury myoglobinuria
History of renal biopsy
Abdominal pain with purplish urine Acute intermittent porphyria

Physical Examination
Anemia, weight loss CKD, malignancies
Palpable abdominal mass Hypernephroma, distended bladder
DRE Smooth enlargement of prostate BPH
DRE hard craggy prostate Prostate Ca
Bone tenderness Bone meta

Laboratory
FBC : Decreased Hb in gross hematuria, malignancy. Increased HB in
polycythemia associated with hypernephroma. Increased WCC in
infection. Low platelet in blood dyscrasia. High ESR in TB, malignancy.
Urine microscopy : RBC indicates Hbnuria, ingestion of substance, high
WCC in infection
Ureum, Creatinine and electrolyte : Renal failure
Clotting screen : Anticoagulant therapy, blood dyscrasia
 CXR : Metastasis, TB
KUB radiograph : Renal calculus

Specific Investigation
PSA : prostate ca, BPH, prostatitis
Sickling test : Sickle cell disease
IVU : Stone, tumor, TB
US : cystic vs solid, stone, urinary tract obstruction
CT : tumor, cyst, obstructive uropathy
Cystoscopy : infection, tumor, stone
Ureteroscopy : tumor, obstruction
Renal angiograph : vascular malformation, tumor
Biopsy : glomerular disease and tumor

Bladder Cancer (Transitional Cell Carcinoma)

Present as painless visible hematuria in older male smoker. Other symptoms
dysuria, blood clots and obstructive symptoms. 90% urothelial cancer.

Risk factor
Male
Smoker
Age >40
Preexisting urothelial cancer (RCC,
ureteral, prostate)
Chronic UTI
Chemical/ toxin exposure

Diagnostic tools
Cystoscopy with biopsy : gold
standard
Hexaminolevulinate fluorescence cystoscopy : for detection of CIS
Multiphasic CT Urograph : improve sensitivity of cystoscopy
US : sensitivity 63%, specificity 99%

Therapy
Transurethral resection if minimally invasive
Intravesicular chemotherapy after operation
Radical cystectomy + cisplatin

Prognosis 10 years survival is 65-72%

Renal Cell Carcinoma (Grawitz)
Present with hematuria, flank pain and renal mass (palpated or seen on
radiograph exam). Usually symptomatic after the disease is advanced. Blood clot
may present, abdominal mass only palpable in thin individual, non tender and
moving with repiration. Fatigue, weight loss, anemia.

Risk factor
Smoking
Obesity
Hypertension
PKD

Histologically
Clear cell (75-85%)
Papillary (10-15%)
Chromophobe (5-10%)
VHL tumor supressor gene is mutated in RCC

Diagnostic
CT scan abdomen : solid renal lesion, thickened irregular walls, also used
for staging
US abdomen: does not meet criteria for simple cyst
Bone scan, CT chest, MRI, PET for distant metastasis

Therapy
Partial/ complete nephrectomy biopsy (diagnostic and therapeutic)
Thermal ablation (cryotherapy)

Prognosis 5 year survival rate

Stage I >90%
Stage II 75-95%
Stage III 59-70%
Stage IV <10%, median survivor of 16-20 months
IgA Nephropathy
Present with hematuria within 12-72 hours of a (usually) Upper Respiratory
Tract Infection (synpharingitic hematuria). Visible/ non visible hematuria
with proteinuria.
Peak incidence is between 20s-40s, leads to CKD in 25 years. Hypertension and
heavy proteinuria may occur in advance state.

Etiology
IgA deposition in glomerular mesangium
No evidence of a role for any specific antigen

Diagnostic
Immunofluorescence and immuneperoxidase studies for IgA deposits
o Benign if absence of proteinuria, hypertension or decreased GFR.
o Severe if proteinuria >500-1000 mg/day, elevated serum
creatinine, hypertension.

Therapy
If benign monitor every 6-12 mo for sign of progression
If severe primarily aid at reducing proteinuria and optimizing BP
o ACEi or ARB optimizing BP and reducing proteinuria
o Fish oil
o Very severe Immunosuppressive agents
o Renal transplant if already progressed to CKD
Thin Basement Membrane Nephropathy
Hematuria with normal renal function, no or minimal proteinuria. Thinned
GBM on electron microscopy.
Most common cause of persistent hematuria in children and adult.

Etiology
Defect in type IV collagen

Diagnostic
Renal biopsy if proteinuria 200-300 mg/ day
Electron microscopy if no proteinuria, normal renal function
Immunohistochemical to distinguish TBMN with early Alport syndrome

Therapy
BP goal <130/80 mmHg
ACEi if proteinuria >1 g/ day

Prognosis : excellent

Infection related GN
New onset of Nephritic syndrome (hematuria, proteinuria, edema,
hypertension), AKI and infection.

Epidemiology
Post streptococcal GN occurs in children
Immunocompromising comorbidities DM, alcoholism.

Etiology
Mostly associated with Streptococcal pharyngitis and impetigo
In children 1-2 wks after pharyngitis and 2-4 wks after impetigo

Diagnostic
ASTO for streptococcal infection
Hypocomplementemia C3 and C4
 Adult may have nephrotic range proteinuria, hematuria RBC cast, while
older adult may have sign of volume overload (increased JVP, S3, edema,
pulmo crackles)
Biopsy is recommended in adult

Therapy
Children Supportive
Adults
o Treat underlying infection
o Antihypertensive, diuretics and sodium restriction for managing
nephritic complication

Prognosis
Complete recovery in children
Adult CKD

Nephrolithiasis
Rapid onset of excrutiating back and flank pain radiate to abdomen and
groin. Increasing pain with movement, associated with nausea, vomiting, dysuria
and urinary frequency.

Etiology
Stones because of supersaturation in urine precipitation and crystallization
Calcium oxalate 75% (hypercalcemic, hyperPTH, excess sodium intake)
Calcium phosphate (sama kayak Ca oxalate)
Uric acid (excess dietary purines, MPD, uricosuric agents, metabolic
syndrome)
Proteus mirabillis struvite formation

Complication
Ureteral obstruction
Pyelonephritis
Sepsis
Renal failure
Diagnostic
CT scan non contrast
US for pregnant woman
Hematuria

Therapy
Pain control NSAID/ Opidoid
Hydration oral/ IV
Uncontrolled pain, nausea and vomiting, AKI hospitalize
Sepsis : Broad spectrum Abx and drainage via nephrostomy
Stone passage
o Nifedipine and tamsulosine
o Lithotripsy
Prevention
 o Reducing phosphate containing soft drinks
o Stop thiazide, citrate supplementation, allopurinol

BPH
Urgency frequency, nocturia, urge incontinence, stress incontinence, hesitancy,
poor flow, straining, dysuria
Diagnostic using DRE
Therapy
Diuretics
Moderate to severe : Alpha bloker (terasozin, doxasozin) + 5alpha RI
(finasteride), or phosphodiesterase inhibitor (tadalafil)

Prostatitis
Abdominal pain, recent UTI, fever, chills, urinary retention, recent prostate
biopsy
Ascending infection through reflux of urine to prostate through ejaculatory/
prostate ducts.
Eti
Ecoli, kleb, proteus, pseudomonas
STD chlamidya
Diagnostic
DRE, urinalysis and culture, PSA.
If abscess occur CT, MRI, TRUS.
Renal function
Therapy
First line Fluoroquinolone, TMP SMX 3-4 wks
Supportive : pain reliever and stool softener
Abscess drainage

Alport Syndrome
Hematuria with strong family history of renal disease and sensory neural
hearing loss
Diagnostic urinalysis with microscopy, SrCr, family history and biopsy.
Dysuria
Pain or burning with or after urination. Most patients with dysuria have a
UTI.
When approaching the DD for dysuria, an anatomic approach to the GUT is
helpful for organization

Skin : Rash causing irritation with urination

Herpes
Irritant contact dermatitis
Syphilitic chancre
Erosive lichen planus

Urethra : From STI

Gonorrhea
Chlamydia
Trichomoniasis

Male genial structure

Epididymis : Epididymitis
Testis : Orchitis
Prostate : BPH, acute/ chronic prostatitis

Female genital structure

Vagina : BV, trichomoniasis, candidiasis, atrophic vaginitis
Uterine/ bladder prolapse
Cervix : N. gonorrhea, c. trachomatis

Bladder
Acute cystitis : Uncomplicated (healthy woman without UT abnormality),
complicated (men, urinary obstruction, pregnancy, neurogenic bladder,
immunosuppression)
Interstitial cystitis

Kidney
Pyelonephritis
Cystitis
Infection of bladder.
Dysuria + Suprapubic pain. Urinary frequency and urgency, hematuria.
No discharge, CVA tenderness, nausea, vomiting, fever. Not associated with
discharge.
Uncomplicated : Cystitis in healthy woman
Complicated : Men, urinary obstruction, pregnancy, neurogenic bladder,
immunosuppression
Elderly : incontinence, delirium, functional decline, acute confusion.

Pathogen
Gram - E. coli (75%), K. pneumonia, Proteus
Gram + S. saprophtycus, E. faecalis, group B strep

Risk factor : Sexual intercourse, use of spermicide, previous UTI, new sexual
partner

Diagnostic
Urinalysis (leukocyte, leukocyte esterase Pyuria, nitrites gram (-),
hematuria)
Urine culture >105 CFU bacteria/ mm, women with cystitis had CFU <102
CT in women with multiple episode of cystitis with same pathogen

Therapy
First line Nitrofurantoin/ TMP-SMX
Quinolon, amoxiclav, beta-lactams
Uncomplicated 1-5 days
Complicated 7-10 days
If symptoms continue within 2 weeks after treatment Resistance
Change antibiotic
If recur beyond 1 month Same standard treatment
Postcoital Abx prophylaxis
Vaginitis

Atrophic vaginitis : estrogen deficiency, post menopause

Cervicitis may occur with vaginitis

Therapy
BV : metronidazole/ clindamycin oral/ IV
Trichomoniasis : Metro/ tinidazol
Candida albicans : Topical antifungal or single dose fluconazole
Atrophic vaginitis : Intravaginal esterogem
Pyelonephritis
Dysuria, flank/ back pain, fever, chills, malaise, nausea, vomiting, CVA
tenderness.
Upper UTI affecting kidney parenchyma.
Because of the ascending infection of the same pathogen that cause cystitis.

Diagnostic
Urine culture : indicated for all patient suspected with PN.
Urinalysis : same as cystitis
CT : indicated if there is concern for concomitant nephrolithiasis/
obstruction.

Therapy
Outpatient
Fluoroquinolone first line
Ceftriaxone, aminoglycoside if quinolone resistance
7-10 days for uncomplicated, 14 days for complicated
Follow up
Inpatient if unstable, inability to tolerate oral medication, pregnancy,
immunocompromised, obstruction
IV quinolone, ceftriaxone, aminoglycoside w/wo ampicillin for 14 days
If fever persist Imaging CT/ US (perinephric abscess, kidney stone or
obstruction) and broaden abx spectrum.

Cervisitis and Urethritis

Cervisitis : Cervical discharge, dyspareunia, dysuria, post coital bleeding
Urethritis : Dysuria, urethral pruritus, penile discharge, dyspareunia,
abdominal/ testicular pain.

Diagnostic
Urethritis
Discharge on PE
Microscopy discharge showing >5 WBC per oil immersion field
Leukocyte esterase on first void urine
Microscopy of first void showing >10 WBC per hpf
Gram stain discharge/ urine culture (+)
Cervisitis
Mucopurulent endocervical discharge
Urine, ureteral, endocervical, vaginal PCR for GO and chlamydia

Therapy
Chlamydia : Azithromycin, doxycycline
GO : Ceftriaxone
Coinfection of GO-chlamydia is high, treat for both.
Abstain from intercourse until 1 wk after single dose treatment
Treat the partner
Urosepsis
Sign of cystitis with lethargy, confusion, orthostasis and SIRS. Hypotension,
thrombocytopenia, hypoxemia, oliguria, metabolic acidosis.
Diagnostic
Urine dipstick
Urine culture
CT scan/ US
Therapy
Hospitalized, admission to ICU
IV antibiotics and volume resuscitation with IV fluid to prevent worsening
sepsis.