An Approach to Hematuria

Definitions:
 Gross hematuria – hematuria observable through direct visual inspection of
the urine. Overall urine color may be pink, red, brown
 Microscopic hematuria – hematuria only detectably by microscopic
examination of the urine (> 3 RBC/ HPF)

Glomerular vs. Non-Glomerular Bleeding

 Glomerular Bleeding
o Immune-Complex Mediated
 IgA Nephropathy
 IgA vasculitis
 Lupus Nephritis
 Infection-related glomerulonephritis
o Anti-GBM Disease
 Goodpasture’s syndrome
o ANCA- associated vasculitis
 Polyangitis with Granulomatosis
 Microscopic Polyangitis
 Churg-Strauss Syndrome
o Genetic Disorders
 Thin basement membrane nephropathy
 Non-Glomerular Bleeding
o Non-Glomerular Kidney
 Pyelonephritis
 Renal Cell Carcinoma
 Polycystic Kidney Disease
 Medullary Sponge Kidneys
o Ureter / Bladder / Urethra
 UTI
 Urothelial cancer (bladder cancer)
 Ureteral Stone
 Ureteral Stricture
 Hemorrhagic Cystitis
 Chemotherapy
 Pelvic Irradiation
 Traumatic Foley Placement or removal
 Recent urological procedures
o Prostate
 BPH
 Prostate Cancer
o Unknown
 Exercise Induced hematuria
 Idiopathic
 o Hematuria Mimics
 Contamination from menstrual blood
 Rhabdomyolysis
 Hemolytic anemia
 Porphyria
 Beet Ingestion
 Fictitious hematuria

Biggest Concern is to R/O Cancer

 Risk Factors for Urothelial malignancies
o Gross hematuria (as opposed to microscopic hematuria)
o Smoking
o Age > 35 – 40 (risk continuing to rise with rising age)
o Male sex
o Exposure to benzenes or aromatic amines (metal, rubber, plastic or
carpeting)
o History of cyclophosphamide therapy
o History of Pelvic irradiation

History
 Chronology of the hematuria (age of onset, abrupt vs. gradual, episodic or
consistent)
 Symptomatology –
o Dysuria  UTI
o Nocturia, weak urinary stream  BPH
o Urgency, frequency, incontinence  Either
 Presence of associated symptoms:
o Flank / groin pain  stone
o Fever / Chills  infection
o Weight Loss  malignancy
o Cough and Dyspnea  pulmonary renal syndrome (Anti- GBM disease
and small vessel vasculitis
o Possible triggers: exercise, urinary instrumentation
 History of kidney stones, smoking, autoimmune disease, chronic infections
(HBV, HCV, HIV), hypertension, chemotherapy, pelvic irradiation, prior
urological procedures
