TOC  | D-Dx    

Hematuria Differential Diagnosis  - Outlines in Clinical Medicine on Physicians' Online 2003

A. Glomerular Disease

1. Glomerulonephritis
   • Proliferative Nephritides
   • Membranoproliferative
   • Lupus Nephritis
   • Anti-Basement Membrane Ab Disease
   • ANCA+ and Other Vasculitides
2. IgA Nephropathy (Berger's Disease)
3. Familial Nephritis (Alport's Syndrome)
4. Benign Familial Hematuria
5. Post-Exercise
6. Severe Hypertension: Malignant Hypertension / Emergency or Scleroderma Renal Crisis

B. Interstitial Renal Disease

1. Polycystic Renal Disease
2. Papillary Necrosis
3. Renal artery embolism
4. Lymphoma
5. Multiple Myeloma
6. Amyloidosis
7. Vascular Malformations

C. Bladder And Other Structures

1. Kidney stones (calculi, nephrolithiasis)
2. Neoplasms:  Urinary Bladder Cancer or  Invasive metastatic cancer
3. Infections
4. Benign Prostatic Hyperplasia (BPH)
5. Urethral Stricture
6. Endometriosis
7. Abdominal Aortic Aneurysm
8. Trauma

D. False Hematuria

1. Vaginal Bleeding
2. Rectal Bleeding
3. Hemoglobinuria / Myoglobinuria
4. Drugs Discoloring Urine: Phenothiazine, Phenazopyridine (Pyridium®), Phenophthalein, Rifampin

Hematuria                   REF: Outlines in Clinical Medicine on Physicians' Online 2003

A. Etiology    

• Urinary Tract Infection
• Pyelonephritis
• Kidney Stone See outline Kidney Stones
• Cancer: Bladder, Kidney, Prostate
• Glomerulonephritis See outline Acute Glomerulonephritis
• Renal Cortical Necrosis
• Polycystic Kidney Disease
• IgA Nephropathy
• Hereditary - thin basement membrane disease
• Determining Microscopic vs. Macroscopic hematuria can be helpful in evaluation

B. Evaluation

• Rule out cystitis, prostatitis
• Abdominal CT scan, or sonogram, or IVP for Stones (will detect ~80% of kidney stones)
• Urinalysis
• Cytology (not early morning specimen) - 3 separate specimens
• Microscopic analysis for casts, protein, crystals
• Critical to rule out bladder carcinoma
• Intravenous pyelogram -avoid with renal failure
• Retrograde cystourethrogram
• Renal Ultrasound

C. Treatment

• Underlying Cause
• Bladder Irrigation with 3-Way Foley Catheter for gross hematuria only
• Cystoscopy with intervention
• Surgery

Micro-hematuria

REF: NEJM June 5, 2003; 348:2330

Definitions of microhematuria vary, however, from 1 to more than 10 red cells per high-power field.

Causes of isolated microscopic hematuria (without proteinuria) can be classified as either glomerular or nonglomerular in origin.

1. Glomerular origin:
   • IgA nephropathy (probably the most common glomerular cause of hematuria),  T
   • Thin basement membrane disease, benign familial hematuria, may be as frequent a cause of isolated glomerular microscopic hematuria.
   • Hereditary nephritis is a less common glomerular cause.   Hereditary nephritis (Alport's syndrome)
   • Mild focal glomerulonephritis of other causes.
2. Nonglomerular sources of microhematuria involving the kidney and the upper urinary tract include neoplasm, nephrolithiasis, cystic disease (including polycystic kidney disease and medullary sponge kidney), papillary necrosis, and metabolic defects such as hypercalciuria or hyperuricosuria. The causes involving the lower urinary tract include disorders (infections, stones, or tumors) of the bladder, urethra, and prostate.   Urologic cancers (mainly of the bladder and prostate) are estimated to account for about 5 percent of cases of microscopic hematuria
3. Uncertain source:
   • Exercise hematuria
   • Over-anticoagulation
   • Unknown benign micro-hematuria

Diagnostic tests:
A thorough evaluation of the urinary system may fail to identify a source of microscopic hematuria. In studies in which both imaging of the upper urinary tract and cystoscopy were performed in patients with microscopic hematuria, a source was not identified in 19 to 68 percent of the patients evaluated.

1. History & physical exam
2. Urinanalysis, urine culture, serum creatinine, CBC, PSA for older man; urine cytology if indicated.
3. Imaging studies: IVP, abdominal sonogram (Ultrasonography is safer, does not involve exposure to intravenous radiographic contrast medium, is appropriate for use during pregnancy, and is less expensive.  Ultrasonography, however, may be limited in its detection of solid tumors that are less than 3 cm in diameter), abdominal CT scan (The source of microscopic hematuria remains obscure in about 70 percent of cases after imaging of the upper urinary tract and examination of urine for evidence of glomerular hematuria. In these cases, it may be necessary to evaluate the lower urinary tract, with particular attention to possible bladder cancer. Cystoscopy is appropriate if risk factors for bladder cancer are present. This procedure is also warranted in older men with asymptomatic microscopic hematuria)
4. Cystoscopy

The American Urological Association has issued guidelines for the evaluation of microscopic hematuria in adults (http://www.aafp.org/afp/20010315/1145.html).

Evaluation of Microscopic Hematuria

06072003