Hematuria - A Diagnostic Approach Douglas Stahura D.O. GVH 8/24/00

Goals Epidemiology Evaluation Differential Diagnosis Case Reports

Hematuria - Epidemiology Definitions Macroscopic - pink, red, or tea colored Microscopic - >4 RBC’s per hpf of spun urine sediment Prevalence School aged - 4% (always check a 2nd specimen) >35 y/o - 13% PPV low, most useful in elderly men

Hematuria - Epidemiology Specific Glomerular causes - Predominate in children and young adults >40 y/o only 5% of cases Neoplasm >40 y/o, Urinary tract 15-20% of cases Children: Wilm’s tumor, Rhabdomyosarcoma of bladder

Hematuria - Evaluation History Physical Urinalysis

Hematuria - Evaluation

Hematuria - Evaluation Urinalysis Proteinuria - indicator of glomerular disease can be up to 500 mg/24 hr in gross hematuria RBC cast - must look at urine with your own eyes Pyuria - look for UTI/STD Crystals Dysmorphic RBC’s

Hematuria - Evaluation Glomerular Dx Renal bx C3,C4, CH50 ASO, ANA, cryoglobulin ANCA, anti-GBM SPEP/UPEP, Ig audio/eye sickle screen Non-glomerular Dx culture Chlamydia, N. gonorrhea renal U/S Flat plate Abd IVP Cystoscopy

Hematuria - Cases Case 1 22 y/o WF gross hematuria x2 days mother of 2: 4y/o, 4mo works 12 hr shift as waitress, 3 in 4 d monagamous x 2 years +/- dysuria, +/- flank pain PE - no trauma UA - pro 2+, WBC 5-10/hpf, Bac 1+

Hematuria - Cases Case 2 65 y/o WM gross hematuria x6 weeks denies pain, freq, hesitancy 50 pack-yr cigarette PE - unremarkable UA - Pro 2+, WBC none, Bac none

Hematuria - Cases Case 3 44 y/o male gross hematuria and episodic flank pain radiating to groin on left side. Unable to find comfortable position. PE - uncomfortable, distressed, restless UA - gross hematuria

Hematuria - Cases Case 4 75 y/o male with microscopic hematuria on screening. Hx of hesitancy and weakened urinary stream. PE - 150/85, enlarged prostate without nodularity/tenderness UA - 8-10 RBC’s/hpf

Hematuria - Cases Case 5 41 y/o male with 2 episodes of gross hematuria over last 24 hours. Completed AF marathon yesterday PE - unremarkable UA - 15-20 RBC’s/hpf

Hematuria - Cases Case 6 52 y/o female with 4 day hx of upper respiratory sx of cough, fever, scant sputum production. Over 24h, progresses to Acute respiratory failure PE - on vent, febrile, normotensive, oliguric, bloody sputum, anemic. UA - microscopic hematuria, + Legionella antigen, occ dysmorphic RBC’s, BUN/Cr = 54/5.5 CXR - B/L patchy infiltrates

Hematuria - Cases Case 7 39 y/o male construction worker presents to ED with L arm swelling and tenderness. Denies trauma. + warmth/erythema x4d Teated with Keflex x 7d. 10 d post ATBX, notices blood in urine PE - L arm nl, 150/85, NAD UA - 5-10 RBC/hpf, occ dysmorphic rbc, no casts, bac, WBC reported.

Hematuria - Cases Case 8 20 y/o Japanese exchange student presents with URI sx x1 day. Cough, low grade fever, headache, myalgias. On day two, notices blood in urine. PE - t=99.2, cough, no sputum, minimal distress. UA - RBC TNTC, Pro 4+, no casts, no bac.