Hematuria

DDx

  • Asymptomatic, transient
    • Trauma
    • Exercise
    • Menses
    • UTI - 10%
    • Ureteral stone - 5%
    • Unknown - 50%
  • Asymptomatic, persistent
    • Cancer (bladder, kidney prostate)
      • 5% microscopic hematuria
      • 30% gross hematuria
    • BPH - 10%
    • Coagulopathy

Risk factors for Malignancy

  • Age >35yo
  • Male
  • Smoker
  • Occupational exposures to benzenes, aromatic amines (eg. printers, painters, chemical plant)
  • History
    • Gross hematuria
    • Dysuria
    • Chronic cystitis
    • Pelvic irradiation
    • Exposure to Cyclophosphamide, aristolochic acid
    • Chronic indwelling foreign body
    • Analgesic abuse (kidney carcinoma)
    • Urological disease

Physical Exam

  • Vitals, Temperature
  • Abdomen
    • Suprapubic tenderness
    • Palpable bladder (r/o retention)
    • CVA tenderness
  • DRE (r/o prostate CA, BPH)
  • Adenopathy (Inguinal/supraclavicular)
  • Edema (r/o glomerulonephritis)

Investigations

  • bhCG
  • Consider Type and Screen (or Crossmatch)
  • Urinalysis
  • Urine microscopy
  • Urine culture
  • CBC. Creatinine, Albumin, INR (Coags)
  • Imaging in gross hematuria or risk factors (CT urography vs. IV urography)
    • Consider urine cytology
    • Consider PSA

Management

  • Consider Nephrology referral
  • Consider Urology referral for cystoscopy
    • If outpatient, give indications to return
      • Darkening of the haematuria that does not clear after a few voidings, despite adequate fluid intake
      • Increasing clot formation that does not clear easily on voiding, or development of urinary retention
      • Worsening pain or fever, despite using analgesics or antibiotics