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Hematuria
What is hematuria?
Macroscopic
Visible haematuria
Pink or red
Microscopic
•Gold standard – Microscopy
•Presence of >3 RBCs per high-powered field
Dipsticks
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Positive – >1 RBCs per high-powered field
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Higher false positives
Symptomatic vs. non-symptomatic
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Lower Urinary Tract Symptoms (LUTS)
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Eg. Dysuria, hesitancy, frequency, urgency
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Macroscopic Haematuria
Microscopic Haematuria
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Causes
Renal
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Malignant renal mass
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Benign renal mass
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Glomerular bleeding
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Structural diseases
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Pyelonephritis
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Hydronephrosis
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Hypercalcinuria / Hyperuricosuria
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Renal vein thrombosis
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Renal artery embolism
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Arteriovenous malformation
Ureteric
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Malignancy
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Calculi
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Strictures
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Fibroepithelial polyp
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Fistulas
Bladder
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Malignancy
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Radiation
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Cystitis
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Prostate/Urethra
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Benign prostatic hyperplasia
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Prostate carcinoma
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Catheterisation
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Urethritis
History and Examination
•History
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Time course
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Infective symptoms
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Urinary symptoms
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Associated symptoms
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Past history
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Social history
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Family history
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•Examination
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Vital signs
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Abdominal
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DRE
Workup
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Significant haematuria:
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Single episode of macroscopic haematuria
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Single episode of symptomatic microscopic haematuria
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Persistent non-symptomatic microscopic haematuria
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Initial investigations
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Exclude transient causes
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Eg. UTIs, exercise induced, trauma, menstruation
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Urine cultures
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Serum creatinine and eGFR
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Measure for proteinuria
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Protein:Creatinine ratio (PCR)
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Albumin:Creatinine ratio (ACR)
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Blood pressure
Urological Referral
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All patients with macroscopic haematuria
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All patients with symptomatic microscopic haematuria
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All patients with asymptomatic microscopic haematuria who are
aged 35 and over
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Nephrological Referral
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Consideration of nephrological referral
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Declining GFR
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>10ml/min within the previous 5 years
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>5ml/min within the last 1 year
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Stage 4 or 5 CKD (eGFR <30)
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Significant proteinuria
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PCR ≥50mg/mmol
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ACR ≥30mg/mmol
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Isolated haematuria with hypertension who are aged ≤40
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Haematuria with coinciding intercurrent infection
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Imaging
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CT Urography
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Non-contrast
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Arterial phase
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Renal parenchymal phase
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Excretory phase
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MR Urography
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Without and with IV contrast
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Ultrasound
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Retrograde pyelogram
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XR IVP
CT Urography
Procedure
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Cystoscopy
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Full visualisation of the bladder, prostate and urethra
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All haematuria patients aged 35 years and over
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All patients with risk factors for urinary tract malignancy
Risk Factors
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Male gender
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Aged 35 and over
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Past or current smoker
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Occupational exposure to chemicals
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Analgesic abuse
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History of gross haematuria
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History of urologic disorder or disease
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History of irritative voiding symptoms
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History of pelvic irradiation
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History of chronic urinary tract infections
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History of exposure to known carcinogens or chemotherapy
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History of chronic indwelling foreign body
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Procedure
Negative Urological Workup
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Annual assessment
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Creatinine / eGFR
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PCR / ACR
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Blood pressure
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Monitor
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Voiding LUTS
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Macrohaematuria
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Significant proteinuria
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Worsening renal function
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Repeat full urological work-up if persistent haematuria
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Consider nephrological referral
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Follow up not required
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2x consecutive negative annual urinalyses
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Rigid cystoscopy
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Continuous Bladder Irrigation
Manual Bladder Washout
Manual Bladder Washout