Hematuria
DDx
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
- Cancer (bladder, kidney prostate)
Risk factors for Malignancy
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
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
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
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
- If outpatient, give indications to return
References:
- CMAJ 2020. https://www.cmaj.ca/content/192/14/E370
- ACP 2016. http://annals.org/aim/article/2484287/hematuria-marker-occult-urinary-tract-cancer-advice-high-value-care
- AAFP 2013. http://www.aafp.org/afp/2013/1201/p747.html
- AUA 2012. http://www.auanet.org/guidelines/asymptomatic-microhematuria-(2012-reviewed-and-validity-confirmed-2016)
- CUA 2008. https://www.cua.org/themes/web/assets/files/guidelines/en/amh_2008_e.pdf
- Emerg Med J 2007. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658267/