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

2. Goals
Epidemiology
Evaluation
Differential Diagnosis
Case Reports

3. 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

4. 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

5. Hematuria - Evaluation
History
Physical
Urinalysis

6. Hematuria - Evaluation

7. 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

14. 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

17. 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+

18. 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

19. 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

20. 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 RBC’s/hpf

21. 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 RBC’s/hpf

22. 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/ CXR - B/L patchy infiltrates

23. 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 RBC/hpf, occ dysmorphic rbc, no casts, bac, WBC reported.

24. 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.