Hematuria

Background

• Microscopic hematuria: the presence of blood on urinalysis
• Macroscopic or gross hematuria: the presence of visible blood in the urine

Etiologies

• Renal:
  • Benign renal mass, including angiomyolipoma, oncocytoma, renal abscess
  • Malignant renal mass, including renal cell carcinoma, transitional cell carcinoma
  • Glomerular bleeding from IgA nephropathy, thin basement membrane disease, Alport syndrome
  • Structural disease, from polycystic kidney disease, medullary sponge kidney
  • Pyelonephritis
  • Hydronephrosis or distension
  • Hypercalciuria or hyperuricosuria
  • Malignant hypertension
  • Renal vein thrombus or renal artery embolism
  • Arteriovenous malformation
  • Papillary necrosis
• Ureteric: malignancy, ureteric stone, stricture, fibroepithelial polyp, post-surgical changes including ureteroiliac fistula
• Bladder:
  • Malignany, including transitional cell carcinoma and squamous cell carcinoma
  • Radiation
  • Cystitis
  • Bladder stones
• Urethra and prostate:
  • Benign prostatic hypertrophy
  • Prostate cancer
  • Prostatic procedures, including biopsy, transurethral resection of the prostate
  • Traumatic catheterization
  • Urethritis
  • Urethral diverticulum

Differential Diagnosis

• Always consider menstruation

Macroscopic Hematuria

• Urine with the appearance of hematuria but without hemoglobin or myoglobin includes:
  • Medications: doxorubicin, chloroquine, deferoxamine, ibuprofen, iron sorbitol, nitrofurantoin, phenazopyridine, phenolphthalein, rifampin
  • Food: beets, blackberries, food colouring
  • Metabolic causes: bile pigments, homogentisic acid, melanin, methemoglobin, porphyria, tyrosinosis, urates

Investigations

• Confirm hematuria
• Consider nephrolithiasis based on clinical exam with or without imaging
  • Treat if identified
• Consider urinary tract infection, based on clinical exam and urinalysis
  • Treat if identified, and repeat urinalysis following resolution of infection to assess for persistent hematuria
• Assess for glomerular bleeding with urinary and serum albumin, serum creatinine, urine microscopy for dysmorphic RBCs, RBC casts, or WBC casts, and assess for hypertension or edema
  • Refer to Nephrology if present
• Assess risk of structural cause, including age >35 years, smoking, prior macroscopic hematuria, exposure to benzenes or aromatic amines, heavy NSAID use, prior urologic disorder, lower urinary tract symptoms, recurrent UTIs, prior pelvic irradiation, prior alkylating agents such as cyclophosphamide, or prior aristolochic acid
  • CT abdomen/pelvis for urography (if not pregnant)
  • Urology to see for cystoscopy
• Otherwise, consider ultrasound of kidney and bladders +/- cystoscopy