HEMATURIA

BASIC COURSE OF DIAGNOSIS

Dr. SARTONO Sp PD

CONTENT

Definition of hematuria
Etiology
Clinical feature
Differential diagnosis
Laboratory tests
Accompanied symptoms

DEFINITION
More than three red blood cells are found in
centrifuged urine per high-power field microscopy
( > 3 RBC/HP).
Normal urine:
no red blood cell or less than three red blood cell

According to the amount of RBC in the

urine, hematuria can be classified as:
microscopic

hematuria:

normal colour with eyes

gross

hematuria:

tea-colored, cola-colored, pink or

even red

ETIOLOGY

Diseases of the urinary systemthe most

common cause
Vascular
arteriovenous malformation
arterial emboli or thrombosis
arteriovenous fistular
nutcracker syndrome
renal vein thrombosis
loin-pain hematuria syndrom
cogulation abnormality
excessive anticogulation

Glomerular
IgA nehropathy
thin basement membrane disease (incl.Alport syndrome)
other causes of primary and secondary glomerulonephritis

Interstitial
allergic interstitial nephritis
analgesic nephropathy
renal cystic diseases
acute pyelonephritis
tuberculosis
renal allograft rejection

Uroepithelium
malignancy
vigorous excise
trauma
papillary necrosis
cystitis/urethritis/prostatitis(usually caused by infection)
parasitic diseases (e.g. schistosomiasis)
nephrolithiasis or bladder calculi

Multiple sites or source unknown

hypercalciuria
hyperuricosuria

System disorders

a. Hematological disorders
aplastic anemia
leukemia
allergic purpura
hemophilia
ITP (idiopathy thrombocytopenic purpura)

b. Infection
infective endocarditis
septicemia
epidemic hemorrhagic fever (Hantaan virus)
scarlet fever (-hemolytic streptococcus)
leptospirosis (leptospire)
filariasis (Wuchereria bancrofti, Brugia malayi)

c. Connective tissue diseases

systemic lupus erythematosus (SLE)
polyarteritis nodosa
d. Cariovascular diseases
hypertensive nephropathy
chronic heart failure
renal artery sclerosis
e. Endocrine and metabolism diseases
gout
diabetes mellitus

Diseases of adjacent organs to urinary tract

appendicitis
salpingitis
carcinoma of the rectum
carcinoma of the colon
uterocervical cancer

Drug and chemical agents

sulfanilamides
cyclophosphamide

anticogulation
mannitol

miscellaneous
exercise

idopathic hematuria

CLINICAL FEATURE
Color

depends on the amount of red blood cell

in the urine and the pH (see slide 4)
normal: light yellow, pH 6.5
pH
acidic: more darker (brown or black)
alkaline: red

DIFFERENTIAL DIAGNOSIS
Polluted
Drug

urine: menstruation

and food: phenosulfonphtha lein (PSP),uric

acid, vegetable
Porphyrism:

porphyrin in urine (+)

Hemoglobinuria

hemolysis
soy-like, very few RBC under the microscopy
occult blood test (+)

HEMOGLOBINURIA
RBC abnormality

Defects of RBC membrane structure and function

(hereditary spherocytosis)

Deficiency of enzymes (favism)

Hemoglobinopathy (thalassemia)

PNH

Mechanical factor (artificial heart valve), infection

or mismatched blood transfusion

LABORATORY TESTS

Three-glass test

Method: collecting the three stages of urine of

a patient during micturition
Result:

the initial specimen containing RBCthe urethra

the last specimen containing RBCthe bladder

neck and trianglar area, posturethra

all the specimens containing RBCupper urinary

tract, bladder

 Phase-contrast

microscopy

to distinguish glomerular from post glomerular

bleeding

post glomerular bleeding: normal size and shape

of RBC

glomerular bleeding: dysmorphic RBC

(acanthocyte)

EXAMPLE OF PHASE-CONTRAST
MICROSCOPY TEST (non-glomerlar)

RBC MCV: 92.8 um3

EXAMPLE OF PHASE-CONTRAST
MICROSCOPY TEST (glomerlar)

ACCOMPANIED SYMPTOMS
Hematuria

with renal colic

renal stone, ureter stone

if with dysuria, miction pause or staining to void: bladder
or urethra stone
Hematuria

with urinary frequency,urgency and

dysuria
bladder or lower urinary tract (tuberculosis or tumor)
if accompanied by high spiking fever, chill and loin pain:
pyelonephritis

 Hematuria

with edema and hypertension

glomerulonephritis
hypertensive nephropathy
Hematuria

with mass in the kidney

neoplasm
hereditary polycystic kidney
Hematuria

with hemorrhage in skin and

mucosa
hematological disorders
infectious diseases
Hematuria

filariasis

with chyluria

--Approaching to the patient

HEMATURIA

(Harrisons Principle of Internal

Medicine,14th Ed)

proteinuria (>500mg/24h)
(-)

Dysmorphic RBC or RBC casts

Pyuria,WBC casts
(-)

(+)

urine culture
eosinophils

Hb electrophoresis, urine cytology,

UA of family member, 24h urinary
calcium/uric acid
(-)
As indicated:
(+)
IVP+/-renal
retrograde
ultrasound
pyelography or
arteriogram of cyst
(-)
(+) aspiration
cystoscopy
biopsy
(-)
(+)
CT scan
open renal biopsy
(-)
follow

(+)

serologic and hematologic

evaluation: blood culture,
anti-GBM Ab, ANCA,
complement, cryoglobulin
HBV,HCV,VDRL,HIV,
ASLO
renal biopsy

ANCA:antineutrophil cytoplasmic
antibody, VDRL:venereal dis. research
laboratory, ASLO: antisteptolysin O,
IVP: intravenous pyelography