Hematuria

This page is for adult patients; for pediatric patients see hematuria (peds)

Background
Macroscopic Hematuria algorithm
  • Make sure hematuria is not myoglobin or bleeding from non-urinary source
  • Hematuria + pain suggests UTI or nephrolithiasis
  • Hematuria + no pain suggests malignancy, hyperplasia, or vascular cause

Common Causes

Clinical Features

Types of hematuria
  • Initial hematuria
    • Blood at beginning of micturition with subsequent clearing
    • Suggests urethral disease
  • Intervoid hematuria
    • Blood between voiding only (voided urine is clear)
    • Suggests lesions at distal urethra or meatus
  • Total hematuria
    • Blood visible throughout micturition
    • Suggests disease of kidneys, ureters, or bladder
  • Terminal hematuria
    • Blood seen at end of micturition after initial voiding of clear urine
    • Suggests disease at bladder neck or prostatic urethra
  • Gross hematuria
    • Indicates lower tract cause
  • Microscopic hematuria
    • Tends to occur with kidney disease
  • Brown urine with RBC casts and proteinuria
    • Suggests glomerular source
  • Clotted blood
    • Indicates source below kidneys

Workup
  • Labs:
    • Urinalysis
      • Microscopic hematuria associated with proteinuria suggests glomerular disease and requires further investigation (as an outpatient)
  • Consider CT imaging to assess for renal tumors, stones, or aneurysm
  • Ultrasound useful to assess for hydronephrosis or a Abdominal Aortic Aneurysm

Blunt Trauma[1]

Renal injuries are associated with:

  • Sudden deceleration injury without hematuria
  • Gross Hematuria
  • Microscopic Hematuria with Shock (SBP<90 mm Hg)
  • The degree of hematuria does not correlate with significance of renal injury

Differential Diagnosis

Hematuria

Pediatric Hematuria
Macroscopic Hematuria Transient Microhematuria Persistent Microhematuria
Blunt abdominal traumaStrenuous exerciseBenign familial hematuria
Urinary tract infectionCongenital anomaliesIdiopathic hypercalciuria
NephrolithiasisTraumaImmunoglobulin A nephropathy
InfectionsMenstruation
Poststreptococcal glomerulonephritisBladder catheterizationAlport syndrome
High feverSickle cell trait or anemia
Immunoglobulin A nephropathyHenoch-Schonlein purpura
HypercalciuriaDrugs and toxins
Sickle cell diseaseLupus nephritis

Management
  • Treat underlying cause
  • Gross hematuria
    • Often associated with intravesicular clot formation and bladder outlet obstruction
      • Use triple-lumen urinary drainage catheter with intermittent or continuous bladder irrigation
        • Adequate urinary drainage must be ensured; otherwise consult urology

Disposition
  • Outpatient management appropriate if:
    • Hemodynamically stable without life-threatening cause of hematuria
    • Able to tolerate oral fluids, antibiotics, and analgesics as indicated
    • No significant anemia or acute renal insufficiency
  • Patients <40 yr: refer to primary care provider for repeat UA within 2wk
  • Patients >40 yr with risk factor for urologic cancer: refer to urologist within 2wk
    • Risk factors:
      • Smoking history
      • Occupational exposure to chemicals or dyes
      • History of gross hematuria
      • Previous urologic history
      • History of recurrent UTI
      • Analgesic abuse
      • History of pelvic irradiation
      • Cyclophosphamide use
      • Pregnancy
      • Known malignancy
      • Sickle cell disease
      • Proteinuria
      • Renal insufficiency
  • Admit:

See Also

Hematuria (Peds) DDx

References
  1. Mee S. et al. Radiographic assessment of renal trauma: A 10-year prospective study of patient selection. J Urology. 1989 May;141(5):1095-8

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