Hematuria in Adults

1. See Also
   1. Pediatric Hematuria
2. Definition
   1. Significant Hematuria: >3-5 Red Blood Cells/HPF
3. Epidemiology
   1. Age under 40 years with Hematuria
      1. Healthy men with Hematuria at one time: 39%
   2. Age over 40 years with Hematuria
      1. Bladder CancerIncidence: 2.5%
4. Risk factors suggestive of significant cause of Hematuria
   1. Tobacco abuse
   2. Occupational exposures (leather dye, rubber, tire)
      1. Benzenes
      2. Aromatic amines
   3. Gross Hematuria
   4. Age over 40 years
   5. Voiding symptoms suggestive of irritation
   6. Urinary Tract Infection history
   7. Analgesic overuse
   8. Pelvic irradiation history
5. Causes
   1. See Adult Microscopic Hematuria Causes
   2. See Medication Causes of Hematuria
   3. Athletes with Running trauma (March Hematuria)
      1. Hematuria transiently related to activity
      2. Recheck Urinalysis in 2 weeks
6. Evaluation: Protocol
   1. Consider non-urinary source (e.g. vagina, rectum)
   2. Urine RBC < 3/hpf
      1. Reassure patient
      2. Repeat Urinalysis in 3-6 months
   3. Urine RBC > 3/hpf with bacteriuria and Urine Nitrite
      1. Treat as Urinary Tract Infection
      2. Repeat Urinalysis in 6 weeks
         1. No urine blood: Observe
         2. Hematuria: Evaluate as isolated Hematuria below
   4. Urine RBC > 3/hpf with renal disease signs
      1. Signs suggestive of renal etiology
         1. Proteinuria (1+ or greater on dipstick)
         2. Serum Creatinine elevated
         3. Dysmorphic Red Blood Cells or Red cell casts
            1. Suggests glomerular cause
            2. No dysmorphic cells suggests interstitial cause
      2. Collect 24 hour urine for protein and Creatinine
      3. Obtain nephrology consultation
   5. Urine RBC > 3/hpf alone (isolated Hematuria)
      1. Suggests urologic cause (non-renal)
         1. Cancer in 20% of gross, <5% of occult bleeding
         2. Isolated Hematuria may occur in 20% of renal causes
      2. Helical CT Urogram
         1. See diagnosis below
      3. Obtain urine cytology (3 first morning voids)
      4. Eliminate benign causes
         1. Menstruation
         2. Strenuous Exercise or sexual activity
         3. Viral illness
         4. Trauma
         5. Genitourinary infection
      5. Consider risk factors above
      6. Obtain Urology consultation and cystoscopy
      7. If evaluation normal
         1. Obtain clotting values and hematologic tests
         2. Consider hematology consultation
         3. If evaluation negative
            1. No further work-up needed
            2. Exceptions: Gross Hematuria, Symptoms
   6. Recurrent or persistant Gross Hematuria
      1. Urology Consultation
   7. Persistent idiopathic Microscopic Hematuria protocol
      1. Repeat Urinalysis every 6 months
      2. Repeat urine cytology every 6 months
      3. Repeat cystoscopy every year
7. Labs
   1. Urinalysis with microscopic exam
      1. Signs of glomerular disease
         1. Urine brown (Coca-Cola color)
         2. Microscopy
            1. Red Blood Cell casts
            2. Dysmorphic Red Blood Cells
         3. Proteinuria
      2. Signs of extraglomerular
         1. Clots of blood
      3. Note dysmorphic Red Blood Cells seen
   2. Voided urine cytology
      1. Obtain three serial first-morning specimens
      2. Evaluate for transitional cell cancer
   3. Collect 24 Hour Urine Protein and Creatinine Clearance
      1. Consider for suspected Glomerulonephritis
   4. Additional tests to consider based on evaluation
      1. Antinuclear Antibody
      2. ASO Titer
      3. Serum complement (C3, C4, C50)
      4. Prostate Specific Antigen
      5. ProTime (PT)
      6. Partial Thromboplastin Time (PTT)
      7. Collect 24 hour Urine Calcium
      8. Collect 24 hour Urine Uric Acid
   5. Urinalysis of "Three Glass Test"
      1. Glass 1: Initiation of urine stream
         1. Hematuria in Glass 1 only suggests Urethral source
      2. Glass 2: Midstream urine
         1. Hematuria in all glasses suggests Bladder or renal
      3. Glass 3: Termination of urine stream
         1. Hematuria in Glass 3 only suggests Prostate source
8. Diagnosis
   1. Helical CT Urogram (preferred)
      1. See CT Urogram for details
   2. Renal Ultrasound
      1. Defines anatomy
      2. Signs of glomerular disease and renal cysts
      3. CT Urogram is usually preferred over Ultrasound
   3. Intravenous Pyelogram
      1. Suspected Nephrolithiasis
   4. Cystoscopy
      1. Extraglomerular source of Hematuria
   5. MRI Urography
      1. Indicated where CT Urogram is contraindicated (e.g. Pregnancy, Children)
      2. Identifies urothelial cancer, Nephrolithiasis and renal tumors
9. References
   1. Cohen (2003) N Engl J Med 348:2330-8
   2. Grossfield (2001) Am Fam Physician 63(6):1145-54
   3. Grossfield (1998) Urol Clin North Am 25:661-76
   4. Sutton (1990) JAMA 263:2475-80