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Dr. shreya! iam sending information- all about hematuria and its management in a text form.if u
go throughit uwill know how to manage.but u have to r/o pseudo hematuria refer page 2&3.

try and see if u can connect Hypertension ,& hematuria by taking detailed history.

Also take h/o catheterization during surgery and if she is on aspirin for any reason.pl tell me about the
follow up.

Hematuria

 Hematuria, or blood in the urine, can be either gross (visible) or microscopic (as defined by more than three to five
     red blood cells per high power field when viewed under magnification). Gross hematuria can vary widely in
appearance, from light pink to deep red with clots. Despite the quantity of blood in the urine being different, the types
  of conditions that can cause the problem are the same, and the workup or evaluation that is needed is identical.

 People with gross hematuria usually present to their doctor with this as a primary complaint. Microscopic hematuria,
     on the other hand, is most commonly detected as part of a periodic checkup by a primary-care physician.

                                     What are the causes of Hematuria?

The causes of gross and microscopic hematuria are similar and may result from bleeding anywhere along the urinary
 tract. One cannot readily distinguish between blood originating in the kidneys, ureters (the tubes that transport urine
 from the kidneys to the bladder), bladder, or urethra. Any degree of blood in the urine should be fully evaluated by a
                                      physician, even if it resolves spontaneously.

  Infection of the urine, stemming either from the kidneys or bladder, is a common cause of microscopic hematuria.
   Kidney and bladder stones can cause irritation and abrasion of the urinary tract, leading to microscopic or gross
   hematuria. Trauma affecting any of the components of the urinary tract or the prostate can lead to bloody urine.
   Hematuria can also be associated with renal (or kidney) disease, as well as hematologic disorders involving the
    body's clotting system. Medications that increase the risk of bleeding, such as aspirin, warfarin (Coumadin), or
 clopidogrel (Plavix), may also lead to bloody urine. Lastly, cancer anywhere along the urinary tract can present with
                                                       hematuria.

                                       How is blood in urine diagnosed?

 The evaluation for blood in urine consists of taking a history, performing a physical examination, evaluating the urine
  under a microscope, and obtaining a culture of the urine. Lower urinary tract symptoms, such as urgency (feeling a
  strong need to urinate) and frequency (needing to urinate frequently), as well as the presence of fever and/or chills
  are suggestive of infection. Recent trauma, even if believed by the patient to have been inconsequential, should be
considered as a potential cause. Abdominal and/or flank pain, especially if radiating to the inguinal or the genital area,
  may suggest kidney stones. All recent medications, including vitamins or herbal supplements, should be reviewed
  with the health-care provider. However, it is important to note that even if the patient has been taking a medication
              that is associated with bleeding, a full workup (as listed below) should still be undertaken.

   The physical exam will focus on possible sources of hematuria. Bruising over the back or abdomen may indicate
trauma. A digital rectal exam should be performed, as findings consistent with prostatitis (for example, tenderness on
  palpation of the prostate) or an enlarged prostate (suggestive of BPH or benign enlargement of the prostate gland)
     may be useful in making a diagnosis. A repeat urinalysis, as well as a urine culture, should be obtained. The
    presence of white blood cells on urinalysis is more consistent with a urinary tract infection. Protein, glucose, or
 sediment in the urine may indicate the presence of a disease of the kidneys. Blood tests are also important, as they
                      will aid in assessing renal function and identifying any clotting abnormalities.
                                                                                                                            2

     In addition to the basic history and physical exam, there are three additional components for any workup of
                                  hematuria: CT scan, urine cytology, and cystoscopy.

 The CT scan is an imaging evaluation of the urinary tract. Prior to the procedure, the patient drinks an oral contrast
agent and a dye is injected intravenously. The patient then goes through the CT scan machine and images are taken
of the abdomen and pelvis. Another test that can be performed, the intravenous pyelogram (IVP), is also a type of X-
ray evaluation of the urinary tract. In this procedure, a dye is injected into the veins, and this is filtered by the urinary
    tract. A series of X-rays are then taken over a 30-minute period to look for abnormalities. The CT scan is more
 commonly performed than the IVP to evaluate the urinary tract and should be considered the test of choice. Both of
  these studies are especially useful for evaluating the kidneys and ureters but not the bladder, prostate, or urethra.
 Therefore, a second examination called a cystoscopy is necessary. This is a simple 10-minute procedure wherein a
thin, flexible cystoscope (or fiberoptic camera) is inserted via the urethra into the bladder in order to directly visualize
  any lesions or sources of bleeding. This is usually done with local anesthetic jelly injected into the urethra. Finally,
    urine cytology involves giving a urine sample to be analyzed by a pathologist for the presence of cancerous or
                                                 abnormal-appearing cells.

 The CT scan is an imaging evaluation of the urinary tract. Prior to the procedure, the patient drinks an oral contrast
agent and a dye is injected intravenously. The patient then goes through the CT scan machine and images are taken
of the abdomen and pelvis. Another test that can be performed, the intravenous pyelogram (IVP), is also a type of X-
ray evaluation of the urinary tract. In this procedure, a dye is injected into the veins, and this is filtered by the urinary
    tract. A series of X-rays are then taken over a 30-minute period to look for abnormalities. The CT scan is more
 commonly performed than the IVP to evaluate the urinary tract and should be considered the test of choice. Both of
  these studies are especially useful for evaluating the kidneys and ureters but not the bladder, prostate, or urethra.
 Therefore, a second examination called a cystoscopy is necessary. This is a simple 10-minute procedure wherein a
thin, flexible cystoscope (or fiberoptic camera) is inserted via the urethra into the bladder in order to directly visualize
  any lesions or sources of bleeding. This is usually done with local anesthetic jelly injected into the urethra. Finally,
    urine cytology involves giving a urine sample to be analyzed by a pathologist for the presence of cancerous or
                                                 abnormal-appearing cells.




                                            How is hematuria treated?

Treatments for hematuria vary widely and depend wholly upon the reason for the bleeding. It is important to note that
 there is often no source found for the hematuria. This should not be a source of major concern, however, since an
appropriate workup effectively rules out the most serious causes of hematuria (for example, cancer). In cases where
   a workup is negative and the cause of the hematuria remains unknown, observation with repeat urinalyses is a
 reasonable option. A blood test to check kidney function and a blood-pressure check should be done as well. Men
 over 50 should discuss with their doctor the yearly prostate-specific antigen (PSA) blood test to screen for prostate
                                                        cancer.

Further discussion of the treatment for hematuria would depend upon the results of the previously mentioned workup
    and the exact cause for the hematuria. The urologist who performs this examination would direct any further
                                    treatment or workup that would be necessary.

 (Hematuria) At A Glance

                           Blood in urine can sometimes be visible only with a microscope.
                         Evaluating blood in urine requires consideration of the entire urinary tract.
              Tests used for the diagnosis of blood in urine include a CT scan, cystoscopy, and urine cytology.
                        Management of blood in the urine depends upon the underlying cause.
    
                  RED URINE
                     Non-Urinary tract source
                          Vagina
                          Anus or rectum
                                                               3


           Pseudohematuria (non-Hematuria related red urine)
               Myoglobinuria
               Hemoglobinuria
               Phenolphthalein Laxatives
               Phenothiazines
               Porphyria
               Rifampin
               Pyridium
               Bilirubinuria
               Phenytoin
               Pyridium
               Red diaper syndrome
               Foods (Beets, Blackberries, Rhubarb)
   Causes of Asymptomatic Gross Hematuria by Incidence
           Acute Cystitis (23%)
           Bladder Cancer (17%)
           Benign Prostatic Hyperplasia (12%)
           Nephrolithiasis (10%)
           Benign essential Hematuria (10%)
           Prostatitis (9%)
           Renal cancer (6%)
           Pyelonephritis (4%)
           Prostate Cancer (3%)
           Urethral stricture (2%)
                                           
4
                                                                                                  5


GPAC: Guidelines and Protocols Advisory Committee

Microscopic Hematuria (Persistent)
Effective Date: April 22, 2009




 Scope

This guideline deals with investigation of blood on dipstick urine testing and persistent
microscopic hematuria in adults (age 19 and over).

Microscopic hematuria is defined as the presence of more than 3 red blood cells (> 3 RBC)
per high power field (HPF) in the centrifuged urinary sediment. It becomes clinically
significant, or persistent, when the result is visible in two of three properly collected urine
samples (taken over a 10-day or longer time period).1




 Risk Factors

Hematuria is the most common sign of bladder cancer. However, the incidence of
bladder cancer in patients with microscopic hematuria is

                                                     4
 Risk Factors for Significant Urologic Disease
      Overuse of analgesic drugs
      Age >40 years; risk increases with age and is twice as high in men
      Exposure to certain drugs (phenacetin, cyclophosphamide, HIV therapies)
      Exposure to pelvic radiation
      History of gross hematuria
      History of urinary tract infection (UTI) or irritative voiding symptoms
      Occupational exposure to chemicals or dyes (e.g. benzenes or aromatic amines)
      Smoking, past or present including exposure to second hand smoke
      Previous urologic disease (e.g. renal calculi, urologic tumours)




 Diagnosis/Investigation (see Algorithm)

Screening the general population for microscopic hematuria is not recommended due to the
low incidence of significant urological disease.5
                                                                                                 6

If blood is detected on urine dipstick testing incidentally, confirm the finding after controlling
for benign causes such as menstruation, exercise, sexual activity, urological instrumentation
or prostate exam. If the repeat dipstick remains positive for blood, confirm with laboratory
macroscopic and microscopic urinalysis. It should be noted that there is not necessarily a
correlation between the degree of hematuria and the severity of the underlying disease. 3

The most typical clinical scenario for finding microscopic hematuria is during the evaluation
of patients with suspected urinary tract infection. Rule out infection prior to
referral. Treat for urinary tract infection if pyuria, bacteria or nitrites are present. It cannot
be assumed that isolated hematuria represents a urinary tract infection.1,7Anticoagulants
including aspirin predispose patients to hematuria only in the presence of urinary tract
disease. It is recommended that patients on anticoagulants with hematuria be
investigated.

 Tests

a) Urinalysis (dipstick):

Microscopic urinalysis can distinguish between dysmorphic red cells (renal parenchyma) and
isomorphic red cells (urinary collecting system) providing initial direction for appropriate
referral and investigation.6 Persistent unexplained microscopic hematuria (two or more
samples out of three) requires investigation prior to referral. Urine dipstick may be
misleading as it lacks the ability to distinguish red blood cells from myoglobin or
hemoglobin. Thus, a positive dipstick test requires follow up examination by microscopic
technique to confirm the presence of red blood cells.1,4

i) Lab sample: For routine urinalysis, a midstream specimen collected in a clean container
without prior cleansing of the genitalia provides a satisfactory sample. If the specimen is
likely to be contaminated by vaginal discharge or menstrual blood, repeat the sample later.

Ideally, the specimen for routine analysis should be examined while fresh. If this is not
possible, refrigeration until examination is recommended. Because it is concentrated, the
first specimen voided upon rising is the preferred specimen for routine urinalysis. Red cells
and casts are more likely to deteriorate if the urine specific gravity is low (<1.015) or the
pH high (≥7.0)4. However, a randomly collected specimen is more convenient for the
patient and is usually acceptable for most purposes.

b) Imaging:

Most adult patients with persistent microscopic hematuria usually require imaging
evaluation.7 However, young women presenting with a clinical picture of simple cystitis and
whose hematuria resolves after successful therapy may not require imaging. Patients who
have clear-cut evidence of glomerulopathy may be appropriately investigated with renal
ultrasound and chest radiography. Renal ultrasonography computed tomography (CT) and
intravenous pyelogram (IVP) are often used to evaluate the upper urinary tract of patients
with microscopic hematuria.1,7 Renal ultrasound is preferred over IVP and CT as it has
comparable sensitivity and specificity, as well as lower morbidity and costs.

Following imaging of the upper urinary tract:
                                                                                                 7

      Urine cytology studies are recommended for all patients with persistent
       microscopic hematuria.
      Cystoscopy is recommended for all patients >40 with persistent microscopic
       hematuria and patients of any age with persistent microscopic hematuria and risk
       factors for bladder cancer.1


 Follow Up

No cause will be found for microscopic hematuria in many cases. If initial ultrasound and
other investigations reveal no disease, cystoscopy for persistent asymptomatic
microscopic hematuria is not warranted in patients under 40 without risk factors
for bladder cancer unless gross hematuria, a significant increase in the number of red
blood cells, or urinary tract symptoms develop. When no specific cause for persistent
microscopic hematuria is found, perform urinalysis and measure blood pressure. 1,3,4 If the
hematuria persists beyond three months, consider referral to a specialist.




 Rationale

Microscopic hematuria is often an incidental finding but may be associated with urologic
malignancy in up to 10 percent of adults.1,8 The incidence of underlying renal or bladder
malignancy in those over 40 with microscopic hematuria increases with age (average age
60) and bladder cancer is twice as common in men as in women. There is considerable
variation between recommendations from population-based studies versus referral based
studies as to the prevalence of significant disease in patients with microscopic hematuria. 9,10




Implications for practice: Hematuria is a frequently encountered symptom that has a broad
differential diagnosis ranging from insignificant etiology to potentially life-threatening
neoplastic lesions. A systematic method can be useful in efficiently and cost-effectively
managing hematuria. Early and appropriate diagnosis of this common symptom results in
improved clinical outcomes
Once hematuria is discovered, its etiology should be investigated through a comprehensive
history, a focused physical examination, laboratory studies, and radiographic imaging.
Microscopic urinalysis is simple yet important in distinguishing glomerular from nonglomerular
sources of bleeding. Intravenous urography, renal ultrasonography, or computed tomography
may be needed to determine the location and characteristics of lesions. Cytoscopy is important in
evaluating lower urinary tract lesions.

NOTE ABOUT INVESTIGATIONS

) Urinalysis (dipstick):
                                                                                                   8


Microscopic urinalysis can distinguish between dysmorphic red cells (renal parenchyma) and
isomorphic red cells (urinary collecting system) providing initial direction for appropriate
referral and investigation.6 Persistent unexplained microscopic hematuria (two or more samples
out of three) requires investigation prior to referral. Urine dipstick may be misleading as it lacks
the ability to distinguish red blood cells from myoglobin or hemoglobin. Thus, a positive dipstick
test requires follow up examination by microscopic technique to confirm the presence of red
blood cells.1,4

i) Lab sample: For routine urinalysis, a midstream specimen collected in a clean container
without prior cleansing of the genitalia provides a satisfactory sample. If the specimen is likely to
be contaminated by vaginal discharge or menstrual blood, repeat the sample later.

Ideally, the specimen for routine analysis should be examined while fresh. If this is not possible,
refrigeration until examination is recommended. Because it is concentrated, the first specimen
voided upon rising is the preferred specimen for routine urinalysis. Red cells and casts are more
likely to deteriorate if the urine specific gravity is low (<1.015) or the pH high (≥7.0)4. However,
a randomly collected specimen is more convenient for the patient and is usually acceptable for
most purposes.

b) Imaging:

Most adult patients with persistent microscopic hematuria usually require imaging evaluation.7
However, young women presenting with a clinical picture of simple cystitis and whose
hematuria resolves after successful therapy may not require imaging. Patients who have clear-cut
evidence of glomerulopathy may be appropriately investigated with renal ultrasound and chest
radiography. Renal ultrasonography computed tomography (CT) and intravenous pyelogram
(IVP) are often used to evaluate the upper urinary tract of patients with microscopic hematuria.1,7
Renal ultrasound is preferred over IVP and CT as it has comparable sensitivity and
specificity, as well as lower morbidity and costs.

Following imaging of the upper urinary tract:

         Urine cytology studies are recommended for all patients with persistent microscopic
                                               hematuria.
Cystoscopy is recommended for all patients >40 with persistent microscopic hematuria and
patients of any age with persistent microscopic hematuria and risk factors for bladder cancer
---------

				
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