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Project: Ghana Emergency Medicine Collaborative

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1 Project: Ghana Emergency Medicine Collaborative
Document Title: Evaluation of Hematuria Author(s): Rodney Smith (University of Michigan), MD. 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1 1 1

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3 Evaluation of Hematuria
Rodney Smith, MD University of Michigan Department of Emergency Medicine St. Joseph Mercy Hospital

4 Objectives Describe the evaluation and management of gross hematuria
Describe the evaluation and management of microscopic hematuria

5 Case Presentation 34 year old female presents with depression and suicidal ideation Recent divorce, not sleeping well Otherwise healthy Normal physical exam CBC, Basic, UDS all normal

6 Case Presentation Urinalysis Normal except 1+ blood Tr protein 2 WBC
12 RBC 2 epi No bacteria

7 Is this patient medically cleared for psych admission?
What further evaluation is necessary

8 Does this patient have hematuria?
>2-3 RBCs per HPF Microscopic hematuria Yellow urine Concentration Gross hematuria Red/brown urine 1 ml blood Presence of clots = post glomerular disease

9 Does this patient have hematuria?
Centrifuge Result Sediment Red Supernatant Red Hematuria Dipstick H=heme Negative Positive Beeturia Phenazopyridine Porphyria Myoglobin Hemoglobin Plasma Color Clear Red Myoglobinuria Hemoglobinuria

10 Evaluation of hematuria
Clues from history and physical Glomerular vs. Extraglomerular Transient vs. Persistent

11 History Infection symptoms? Flank pain, especially unilateral
Cystitis: dysuria, frequency Pyelonephritis: flank pain, fever Recent URI? Flank pain, especially unilateral Stone Blood clot Malignancy

12 History Symptoms of prostatic obstruction Coagulopathy BPH Malignancy
Therapeutic range Culclaure TF Arch Intern Med 1994 Rate of hematuria in treated and controls equal 81% with hematuria had identifiable cause

13 History Relationship with menstruation Sickle cell disease/trait
Endometriosis Contamination Collection of urine specimen Sickle cell disease/trait Hereditary disorders Polycystic kidney disease Hereditary nephritis

14 Glomerular vs. Extraglomerular
Urinalyis Red cell casts Proteinuria > 1+ Not seen in gross hematuria Red cell morphology Deformed as they pass thru basement membrane Osmotic injury in nephron Urine color Smoky brown = methemoglobin Blood clots

15 Transient vs. Persistent
Transient usually benign Infection Stones Exercise May be seen in patients with malignancy

16 Risk-factors for Malignancy
Age > 40 Smoking history Occupational exposures Printers, painters, chemical plant workers Gross hematuria Chronic irritative voiding symptoms History of pelvic irradiation Analgesic abuse

17 Case 1 22 yo female 2 days of dysuria, frequency, urgency
Now with hematuria No fever, no flank pain LMP 2 weeks ago, not sexually active Normal VS Suprapubic tenderness on exam

18 Case 1 Further evaluation?

19 Case 1 Over the counter meds? Urinalysis Bloody urine
1+ Leukocyte esterase > 100 WBC > 100 RBC 2+ bacteria

20 Urinary Tract Infection
Does this patient need a urine culture?

21 Urinary Tract Infection
Urine culture in Relapse Suspicion for pyelonephritis Flank pain Fever Treatment Phenazopyridine Antibiotics 3 days 7 days

22 Case 2 43 yo male, previously healthy Gross hematuria 2 days ago
Acute onset of severe right flank pain Radiates to groin Diaphoresis, nausea, emesis X 1 Can’t find comfortable position Mild right CVA tenderness

23 Case 2 Initial treatment?

24 Case 2 Initial treatment IV toradol, anti-emetics, narcotics prn
Urinalysis 1+ blood 12 RBC No WBC, bacteria IV fluid bolus?

25 Renal Colic Passage of stone from kidney to bladder
Localization of pain often related to site of stone Lower ureter/UVJ groin Family history Recurrence Concomitant infection Mimics AAA Ectopic pregnancy

26 Renal Colic Non-contrast CT USN Sensitivity 95% Specificity 99-100%
Other diagnosis Use with KUB USN Obstruction In ability to give contrast Recurrent stone

27 Renal Colic NSAIDs Narcotics Calcium channel blocker Alpha blocker
Size and location

28 Case 3 73 yo male Gross hematuria for 2 days
Unable to void for past 8 hours Mildly hypertensive Obvious distress Bladder distention on physical exam Foley catheter Bloody urine Blood clots

29 Case 3 Next steps?

30 Case 3 CBC Basic Coumadin: INR Urinalysis, Urine culture
Bladder irrigation

31 Gross Hematuria Infection 25% Stone 20% VS seldom unstable
Assure urinary drainage History of blood clots Size of clots Ease of passage of urine

32 Gross Hematuria Clot retention Followup Foley catheter 16 F or larger
Three-way catheter Discharge with catheter vs. removal Followup

33 Case 4 31 yo male Completed first marathon Blood in urine U/A
Red urine >150 RBC No WBC, bacteria, protein

34 Exercise-induced Hematuria
Contact sports Non-contact sports Long-distance running 10-20% Rowing Swimming Cycling

35 Exercise-induced Hematuria
Mechanism Increased urinary excretion Long-distance running/cycling Bladder trauma Bicycling Urethra trauma ? Renal ischemia Nutcracker syndrome

36 Exercise-induced Hematuria
Rule-out myoglobinuria Followup Clears within one week Consider full workup with risk factors for malignancy

37 Case 5 34 yo female with 1 week of progressive swelling in the lower extremities No chest pain, dyspnea, orthopnea, abdominal pain or distention VS 148/ % Exam normal except for 2+ pre-tibial pitting edema

38 Case 5 CBC normal Basic normal except BUN 24 Creat 1.42 U/A 3+ protein
12 RBCs No WBCs, bacteria

39 Glomerulonephropathy
ED care is usually supportive Treat hypertension if emergency/urgency Close followup Admission criteria Acute renal failure Hypertensive emergency/urgency Oliguria/anuria Electrolyte abnormalities CHF/volume overload

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