; Hematuria
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Tintinalli’s Chap. 97
•   Painful - infection
•   Painless – neoplastic, hyperplastic, vascular
•   Gross – urine appears “RED”; lower tract prob.
•   Microscopic – > 5 RBC’s/hpf; kidney dz
•   False hematuria = urine appears bloody, but
    dipstick results are neg. for blood and no
    RBC’s on micro
    – Free hgb, myoglobin, porphyrins
• Table 97-1; 97-2; 97-3
• Initial hematuria = blood at beginning of
  micturition with subsequent clearing
  – Urethral dz.
• Occuring b/w voiding (staining underclothes)
  & voiding urine is clear = lesions at distal
  urethra or meatus
• Total hematuria = blood throughout
  micturition indicates dz of kidneys, ureters or
• Terminal hematuria = dz at bladder neck or
  prostatic urethra
• Young pts: nephrolithiasis or UTI;
  glomerulonephritis (poststreptococcal); immune
  complex dz, SCC, HSP; Goodpasture syndrome;
  Wilms tumor
• Older pts: infections or nephrolithiasis; renal,
  bladder or prostate CA; anticoagulant use; AAA
  can expand and erode into urogential tract;
  malignant hypertension; embolic renal infarction;
  renal vein thrombosis
• Pregnancy: UTI; nephrolithiasis or preeclampsia
• HIV pts: viral renal infection; glomerulonephritis;
  UTI; chlamydial and gonococcal urethritis; chronic
  Hep B infxn; neurogenic bladder;
  thrombocytopenia; uroepithelial Kaposi sarcoma;
  urethral trauma
• Diagnosis:
  – Clean catch midstream urine for U/A
  – Cath urine if woman has vag. d/c, menstrual or
    vag. Bleeding (cath urine will rarely exceed 3
  – Can screen with dipstick but false negs/pos may
  – Abnormal RBC morphologic characteristics, RBC
    casts & proteinuria suggest glomerular source
  – If normal RBC’s then infection probable
  – Imaging (IVP, CT, renal US)
• Gross hematuria in blunt or penetrating
  trauma to abd, flank, or back requires
  aggressive approach to dx
• Tx directed at cause
  – UTI = axbx
  – Nephrolithiasis = hydration & analgesics
  – Systemic dz = directed at cause
• Discharge pts that have min. or no sxs,
  tolerate PO, and have no comorbid conditions
  – Also should not have significant anemia or renal
• May need to use 3-way foley to irrigate
  bladder until clear before d/c pt
  – Prevent clots in the urethra that would cause
    bladder outlet obstruction
• Admit pts:
  – Intractable pain
  – Do not tolerate PO
  – Significant comorbid illnesses
  – Bladder outlet obstruction
  – Hemodynamic instability
  – Life-threatening cause of hematuria
  – New dx of glomerulonephritis
• Don’t forget in pregnant pts that this could be
  a sign of preeclampsia, pyelonephritis, or
  obstructing nephrolithiasis
  – Consult OB and admit
• Trauma
• Other injury (i.e. tumor w/ erosion)
• Inflammation (common in men <40 y. o.)
• Infection (common in men <40 y. o.)
• *Instrumentation of urinary tract
• *Radiation therapy
• Prostate tumors or BPH (men > 40 y. o.)
*most common
• Testicle tumors, vascular abnormalities, cyts
• Systemic factors: hemophilia, coagulopathies,
  oral anticoagulants, hypertension, leukemia,
  lymphoma, scurvy

• H&P
• U/A
• Tx underlying cause (if one identified)
  – Infxn = axbx
  – Urologist F/U (esp. if > 40 y.o.)

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