Haematuria A Challanging Medical

HAEMATURIA
A Challenging Medical Problem

By
TAREK MEDHAT ABBAS, MD
Lecturer of Nephrology
Urology & Nephrology Center
Mansoura University
Egypt
Urology & Nephrology Center, Mansoura University, Egypt
Haematuria
Definitions:
Normally the number of RBCs in urine
should not be more than 5 RBCs/ high
power field on microscopic
examination of fresh centrifuged So,
urine sample.
haematuria is defined as a secretion of
more than 5 RBCs/ HPF in urine.
www.MansFans.com

Dete ction & q uantification
of hematur ia
Screening test ( dipsticks )
- 0.02-0.03 mg/dL of Hb, myoglobin
- ~5-20 RBC/mm³
Semiquantitative estimation
- centrifugation of 10-15 ml of urine
- resuspention of sediment in 1 ml of
residual urine
- high-power microscopy
Counting chamber –
the number of cells in 1 microliter of unspun
urine
Cl assi ficat ion of
hematu ria
Macroscopic - Microscopic
Symptomatic - Symptomless
Transient - Persistent
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Haematuria may be the only symptom or
may be associated with other manifestations,
according to the cause e.g. loin pain and fever
with infection and renal colic with renal
stones.
Haematuria could be gross (causing red-
coloured urine) or microscopic (urine
appears normal but RBCs are seen on
microscopic examination). In gross
hematuria, urine looks red if alkaline, but
brown or coca-cola like if urine is acidic due
to denaturation of the hemoglobin.
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Hematuria
Transient phenomenon Sign of

of little significance serious
renal disease
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Cause s o f Hematuria
Kidney disease
Lesions along the urinary tract
Conditions unrelated to kidney and

urinary tract www.MansFans.com

First: PRE-RENAL
Hemorrhagic blood disease
Sickle cell anemia
Malignant hypertension
om
s.c
an
Use of anticoagulant
sF
an
M
w.
Liver disease
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Haematuria of renal origin:
 Glomerular haematuria:
Primary glomerular disease (e.g. IgA nephropathy,

mesangial proliferative glomerulonephritis or
crescentic glomerulonephritis)
Secondary glomerulonephritis i.e. renal

involvement is a part of systemic disease
(e.g. post-strephococcal glomerulonephritis, Henoch-
Schönlein purpura, SLE, polyarteritis nodosa).

Renal infection and tubulointerstitial
diseases: Pyelonephritis, renal papillary
necrosis, tuberculosis, and toxic
nephropathies.
Stone disease, idiopathic hypercalciuria
Renal neplastic diseases: Renal cell
carcinoma, transitional cell carcinoma of the
renal pelvis and others.
Hereditary renal diseases: Modularly,
sponge kidney, polycystic kidney disease,
Alport’s syndrome, and thin basement
membrane disease.
Loin-pain haematuria syndrome.
Coagulation defect: use of
anticoagulant, liver disease and
thrombocytopaenia.
Renal vascular disease: Renal
infarction, renal vein thrombosis or
malignant hypertension.
Exertional haematuria.
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Haematuria of ureteral origin:
 Nephrolithiasis.
 Malignancy.
 Ureteral inflammatory condition
secondary to nearby inflammation
e.g. diverticulitis, appendicitis or
salpingitis.
 Ureteral trauma e.g. during
ureteroscopy.
 Ureteral varices, aneurysms, or
arteriovenous malformation.
Haematuria of bladder origin:
 Infection: schistosoma, viral or
bacterial cystitis.
 Neoplasm.
 Foreign body in the bladder e.g.
stones.
 Trauma: During instrumentation or
accidental.
 Drug: e.g. cyclophosphamide induced
haemorrhagic cystitis.www.MansFans.com
Hematuria of urethral (or associated
structures) origin:
 Urethritis: foreign body or

local trauma to the urethra.
 Prostate: Acute prostatitis,

benign prostatic hypertrophy.
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Acute nephri ti c
syndr ome
Hematuria
Proteinuria
Reduced renal function
Edema
Hypertension
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Idio path ic
Hyp erc alciuria
Definition: Calcium excretion > 4
mg/kg/day
Urinary Ca/Creatinine > 0.2
Possible mechanism of hematuria:
microcrystals damaging the tubular or
mucosal epithelia. Resolution of
hematuria with anticalciuric therapy

Alport syndrome
- her edi tary disorder of G BM
X-linked dominant
om
s.c
an
sF
Autosomal recessive
an
M
w.
ww
Autosomal dominant

Renal disea se
Macro /Microhematuria
Proteinuria
Nephrotic syndrome
Hypertension
Renal failure- males
Progressive or juvenile – 20 y
Nonprogressive – 40 y
Hearing defe cts
Sensorineural bilateral
Never congenital
Boys- 85% . Girls – 18% < 15y
Progression of hearing loss parallels

renal impairment

Diagnosi s of Alport
sy ndrome
Hematuria with or without proteinuria
Hypertension
Renal failure
Ocular defects – anterior lenticonus
Familial hematuria
Sensorineural hearing loss
Progression to renal failure occurring
in at least one affected subject
ALPORT’S SYNDROME
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Fam il ial benign essenti al
hematuri a
Familial hematuria without

proteinuria and without progression
to renal failure or hearing defect
Diffuse attenuation of the GBM is
usually considered the hallmark of
the condition
It’s non pathognomonic of FBEH

Contin ue
Autosomal dominant trait
Normal antigenicity of the GBM

Thi n base ment membr an e
nephropathy
Hematuria
Proteinuria
Attenuation of the GBM
In children may be Alport
In adults m/p benign disorder
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HERE DITA RY
NEP HR OP ATHY
Benign Familial Alport Syndrome

Hematuria
Overlap of histological findings
The prognosis appears to be depend more on the degree of

clinical expression in other members of the family and less
on the histological findings

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Hematuri a not repr ese nt ing
ki dney o r uri nar y tract d isorder
Following exercise
Febrile disorders
Gastroenteritis with dehydration
Contamination from external

genitalia
Transient microscopic haematuria is
relatively common. Up to 39% of adults
between ages of 18 and 33 may have
microscopic haematuria at least once, and
up to 16% may have it in two or more
occasions. Therefore, an extensive workup
is not warranted except in high-risk
patients, > 50 years of age and those
patients with other clinical or urinary
abnormalities.
Patterns Of Haematuria
Initial is usually urethral.
Terminal hematuria is usually prostatic or

bladder origin.
Total hematuria is either bladder ureteral

or renal origin.
www.MansFans.com

Differential Diagnosis of Haematuria:
A. First, haematuria should be differentiated
from other causes of red or brownish urine:
Dipsticks (Hemastix) will be positive with
haematuria, hemoglobinuria (hemolysis)
and with myoglobinuria (muscle damage)
but negative with other causes e.g.
prophyrins (in porphyria), bile (in
jaundice), melanin (in melanoma),
alkaptonuria, food dyes and drugs as PAS
or phenylphthalein.
Microscopy will show RBC’s only with
haematuria.
False positive test for haematuria:
 Haemoglobinuria.
 Myoglobinuria.
 Ascorbic acid.
False negative test for hematuria:

 Highly diluted urine.
 Haematuria could be glomerular (because
of glomerular disease, sometimes called
medical); or non glomerular (sometimes
called surgical). Glomerular haematuria
could be differentiated from non
glomerular haematuria by:
1. The shape of RBCs in urine are small and
dysmorphic in cases with glomerular
haematuria while it will be normal in case
of non glomerular haematuria.
1. Means corpuscular volume of RBCs in urine
of patient with glomerular haematuria is
smaller (< 72 FL) than that in peripheral
blood, but in non glomerular cases is equal.
2. Proteinuria is present in most cases of
glomerular hematuria but not in cases of non
glomerular hematuria.
3. Casts, especially red cell casts are seen in
glomerular haematuria.
4. Blood clots indicate non-glomerular bleeding
and can be associated with pain & colic.
5. Three-glass test.
Glo merular v ers us
extr aglo meru lar b leedin g
Urinary finding Glomerular Extraglomerular
Red cell casts May be present Absent
Red cell Dysmorphic Uniform

morphology
Proteinuria May be present Absent
Clots Absent May be present
Color May be red or May be red

brown
Isolated Hematuri a
(mi croscopic)
No other urinary abnormalities

No renal insufficiency
No evidence for systemic disease
Incidence ( school-aged children )

4-6% - single urine examination
0.5-1% - repeated testing over 6-12
months
Et iol ogi es o f isol ated
Hem at uria
Glomerular
- Benign Recurrent or Persistent Hematuria
1.Sporadic
2.Familial
- IgA Nephropathy
- Alport syndrome
- PSAGN
Non-glomerular
- Idiopathic Hypercalciuria
- Cystic Kidneys
- Urinary Tract obstruction
- Tumors
- Trauma www.MansFans.com

He ma turia wit h f amil ia l
associatio n
Glomerular
- Benign Familial Hematuria
- Alport syndrome
Non-glomerular
- Idiopathic Hypercalciuria
- Polycystic Kidney Disease
- Urolithiasis
- Tumors

Approach to a case of haematuria
First exclude haemoglobinuria and

myoglobinuria since both of them can
also cause positive dipstick test for
haematuria. This is done by
microscopic examination of fresh urine
sample. In case of haematuria, RBCs
could be seen while in the other two
conditions no RBC’s could be seen.
In case of myoglobinuria, clinical
examination may show manifestations
of muscle disease and the examination
of urine by immunoelectrophoresis may
show myoglobin.
In case of haemoglobinuria,
manifestations of haemolysis may be
evident
Eval uation of Hematuri a
History
Detailed review of family history

hematuria
proteinuria
renal insufficiency
deafness
stones
Precipitating factors
infection
exercise
Abdominal pain
HSP
hydronephrosis
pyelonephritis
urolithiasis

History Taking
Past history （ previous episodes, recent
　 food and drug ingestion, exercise,
　 instrumentation, menstruation… ）
Dysuria ?
Associated bladder irritability or flank pain ?
Time of hematuria
 initial: urethritis, stricture, meatal stenosis
 total: bladder, ureter, kidney
 terminal: bladder neck or prostatic urethra

History Taking (2)
Associated symptoms
Fever, chills, other bleeding point, dyspnea,
recent URI,
Painful hematuria: stone, inflammation, cancer

bladder, cancer prostate, SEP, trauma
Painless gross hematuria

 consider tumor

Evaluat ion of Hemat uria
Phys ical Ex amin ation
I- GENERAL EXAMINATION:
Growth failure
Hypertension
Pallor
Edema
Rash
Examination of the skin for hemorrhagic
spots
Abdomen: search for a mass or tenderness
General manifestations of the cause

LOCAL EXAMINATION
• External genitalia: bleeding
infection
trauma
PR examination: prostate or bladder
cause
Suprapubic tenderness or mass
Tender loin
Palpable renal mass www.MansFans.com

INVESTIGATIONS
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Study of hemorrhagic profile
Blood picture:
Sickle cell anemia
Lymphoma
leukemia

Urine analysis
Volume: low in nephritic syndrome

Colour: red in macroscopic hematuria,
smokey in nephritic syndrome
Bilharzial ova
Crystals
Malignant cells

Examination of urine for:
 Proteinuria.
 Casts.(RBC in nephritic syndrome, PUS
cells in UTI, WBC in pyelonephritis)
 Pus.
 Bacteria (specific and non specific)
 Culture (Ordinary and special)
 PCR (TB-DNA)
Radiological investigations
Ultasound, plain X-ray, I.V.P. (if

serum creatinine is normal), CT,
MRI and possibly angiography, for
the diagnosis of surgical diseases
e.g. stone, malignancy, infection, or
malformations.
OTHER INVESTIGATIONS
RBCs in urine could be examined for its shape
to differentiate glomerular (small, distorted)
from non glomerular causes (by phase contrast
microscopy).
Kidney function tests.
Specific investigations for diagnosis of systemic
disease causing haematuria e.g. SLE.
Endoscopic study: to diagnose neoplastic
disease , UB ulcers
Kidney biopsy: for glomerular haematuria.
www.MansFans.com

Dipstick+ Uriinalysis (UA) with microscopy
Transient cause?
• Sexual intercourse • Menstruation Yes RBCs present
Yes • Infection • Vigorous exercise
• GU instrumentation
Repeat UA when NO
condition resolved Persistent hematuria
• Hemoglobinuria
Glomerular etiology? • Myoglobinuria
• Proteinuria > 500 mg/24 hr
Nephrology • UA shows RBC casts +/- dysmorphic RBCs
referral Yes • Renal insufficiency
Biopsy Appropriate work up

NO
and therapy
Imaging:
Cystic disease • Ultrasound • Spiral CT
• Age > 50
• Aromatic amine Age < 50
Nephrology • Mass • Hydronephrosis
referral • Stricture exposure
• smoker
Surveillance
Urology referral
• Cysto+/-
• Cytology
Evaluation of haematuria
Work-u p o f a chil d wi th
Hematuri a
Phase I:
Urinalysis ( sediment examination )
RBC’s morphology
Urine culture
BUN, Creatinine, Proteins, Electrolytes
Antibodies against strept. & other antigens
Complement, ANF, Immunoglobulins
Renal US
Urinalysis of 1st degree relatives
24h urine collection: Ca, Creat.,Protein, UA
Phase II:
Hearing test
Cystoscopy
Renal biopsy
www.MansFans.com

Iso la ted h ematuria
The child needs to be monitored for the
appearance of new clinical signs:
hypertension
proteinuria
changes in the pattern or severity of hematuria
If there is no change in the first year,observation

at yearly intervals is adequate

Is ola te d h ematu ria Possible
outc ome
Disappearance of hematuria
Hematuria will persist -

follow-up should be continued
The hematuria will no longer be

“isolated” - further investigation

Most common causes of hematuria by age and
sex
Age/sex Common causes

0-20 AGN, UTI,
congenital urinary tract
anomalies with obstruction
20-40 male UTI, stones, bladder tumor
40-60 female bladder tumor, stone, UTI
>60 male BPH, bladder tumor, UTI
>60 woman Bladder tumor, UTI

Treatment Of Haematuria
Treatment of the cause.
Haemostatic e.g.:
 Cyclokapron.
 Vitamin K
 DDAVP
 Frish frozen plasma.
 Haematenics and blood transfusion.

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HAEMATURIA

A Challenging Medical Problem

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Transient phenomenon Sign of

Urology & Nephrology Center, Mansoura University, Egypt

Lesions along the urinary tract

Conditions unrelated to kidney and

Urology & Nephrology Center, Mansoura University, Egypt

Sickle cell anemia

Urology & Nephrology Center, Mansoura University, Egypt

Primary glomerular disease (e.g. IgA nephropathy,

Secondary glomerulonephritis i.e. renal

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

 Urethritis: foreign body or

 Prostate: Acute prostatitis,

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Boys- 85% . Girls – 18% < 15y

Progression of hearing loss parallels

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Familial hematuria without

Urology & Nephrology Center, Mansoura University, Egypt

Autosomal dominant trait

Normal antigenicity of the GBM

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Benign Familial Alport Syndrome

Overlap of histological findings

The prognosis appears to be depend more on the degree of

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Gastroenteritis with dehydration

Contamination from external

Terminal hematuria is usually prostatic or

Total hematuria is either bladder ureteral

Urology & Nephrology Center, Mansoura University, Egypt

False negative test for hematuria:

Red cell casts May be present Absent

Red cell Dysmorphic Uniform

Clots Absent May be present

Color May be red or May be red

No other urinary abnormalities

Incidence ( school-aged children )

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

First exclude haemoglobinuria and

Detailed review of family history

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Painful hematuria: stone, inflammation, cancer

Painless gross hematuria

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Urology & Nephrology Center, Mansoura University, Egypt

Volume: low in nephritic syndrome