Hematuria

DEFINITION
More than three red blood cells are found in
centrifuged urine per high-power field microscopy
( > 3 RBC/HPF).

Normal urine:
no red blood cell or less than three red blood cell
Blood in the urine (hematuria) can originate
from any site along the urinary tract and,
whether gross or microscopic.
According to the amount of RBC in the urine,
hematuria can be classified as:
microscopic hematuria:
normal colour with eyes
gross hematuria:
tea-colored, cola-colored, pink or even red

Hematuria can be measured quantitatively by any
of the following:
(1) determination of the number of red blood
cells per milliliter of urine excreted (chamber
count),
(2) direct examination of the centrifuged urinary
sediment (sediment count) or
(3) indirect examination of the urine by dipstick
(the simplest way to detect microscopic
hematuria).

For upper tract sources,
stone disease accounts for 40%,
medical kidney disease (medullary sponge kidney,
glomerulonephritis, papillary necrosis) for 20%,
renal cell carcinoma for 10%, and
urothelial cell carcinoma of the ureter or renal
pelvis for 5%.
The lower tract source of gross hematuria (in
the absence of infection) is most commonly
from urothelial cell carcinoma of the bladder.
Microscopic hematuria in the male is most
commonly from benign prostatic hyperplasia
Drug ingestion and associated medical
problems:
Analgesic use (papillary necrosis)
cyclophosphamide (chemical cystitis)
antibiotics (interstitial nephritis)
Clinical Findings
gross hematuria occurs, a description of the timing
(initial, terminal, total) may provide a clue to the
localization of disease.
Associated symptoms (ie, renal colic, irritative voiding
symptoms, constitutional symptoms) should be
investigated.
Physical examination should emphasize signs of
systemic disease (fever, rash, lymphadenopathy,
abdominal or pelvic masses) as well as signs of medical
kidney disease (hypertension, volume overload).
Urologic evaluation may demonstrate an enlarged
prostate, flank mass, or urethral disease.
Laboratory Findings
Initial laboratory investigations include a
urinalysis and urine culture.
Proteinuria and casts suggest renal origin.
Irritative voiding symptoms, bacteriuria, and a
positive urine culture in the female suggest
urinary tract infection
Further evaluation may include urinary
cytology to assist in the diagnosis of bladder
neoplasm.
Imaging
Upper tract imaging (usually abdominal and
pelvic CT scanning without and with contrast)
may identify neoplasms of the kidney or
ureter as well as benign conditions such as
urolithiasis, obstructive uropathy, papillary
necrosis, medullary sponge kidney, or
polycystic kidney disease.
The role of ultrasonographic evaluation of the
urinary tract for hematuria is unclear.
Cystocopy
Cystoscopy can be used to assess for bladder
or urethral neoplasm, benign prostatic
enlargement, and radiation or chemical
cystitis.
Evaluations
In patients with negative evaluations, repeat
evaluations may be warranted to avoid a
missed malignancy; however, the ideal
frequency of such evaluations is not defined.
Urinary cytology can be repeated in 36
months, and cystoscopy and upper tract
imaging after a year.