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