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Hematuria

Microscopic haematuria

> 3 red bloods cells / high powered field

 

Potential causes:

  • Cancer (any urological malignancy)
  • Infection/inflammation
    • UTI, pyelonephritis, urethritis
    • TB, schistosomiasis
    • STI
  • Stones
    • Bladder, kidney, ureter
  • Trauma
  • BPH
  • Medical renal disease
  • Radiation cystitis
  • Other benign
    • Exercise induced, papillary necrosis, endometriosis, interstitial cystitis

 

Diagnosis rates:

  • 1/3 to 2/3 have an identifiable cause found on work up
  • Cancer in around 4 % of cases
    • More likely with risk factors, more red cells, and age
  • Only a quarter of patients with microscopic haematuria are referred for investigation

 

History:

  • Risk factors for urothelial malignancy
    • Smoking, occupational exposure, age, male, analgesic abuse, irritative voiding symptoms, radiation to pelvis, chronic UTI, long term catheterisation, cyclophosphamide
  • Directed at identifying cause
    • History of trauma
    • Hypertension or family history of medical renal disease
    • History of trauma
    • Symptoms suggesting stone disease
    • Symptoms suggesting UTI
    • Urological/pelvic surgical history
    • Baseline LUTS
  • Medications / anticoagulants / bleeding diathesis

Exam

  • As usual – ?BPH ?flank mass ?pelvic mass, blood pressure

Investigation:

  • Varies by guidelines
  • Repeat urine microscopy and culture (consider checking for proteinuria)
  • Upper tract imaging for all – ultrasound or CT IVP
    • Depending on risk factors, age, renal function
    • AUA – ultrasound for low/intermediate risk, CT IVP or MR urogram preferred for high risk
    • Consider CT if concerns for stones, or other alternate upper tract diagnosis best suited for CT
  • Cystoscopy
    • Recommended for any risk factors
  • Cytology
    • Not recommended in initial workup in AUA guidelines except for risk factors for CIS
    • Often not recommended in guidelines or only in negative work up otherwise

 

How to follow up after negative workup?

AUA recommendations:

  • Repeat urinalysis within 12 months
    • Subsequent normal urinalysis – no further workup needed
    • Persistent microhaematuria – shared decision making
    • If develops gross haematuria or new symptoms – further evaluation

Key points:

  • Women have longer delays to diagnosis for bladder cancer than men
  • Risk stratification is the key to haematuria workup
  • Symptomatic microhaematuria has higher cancer risk than asymptomatic
  • UTIs should be treated, and urine microscopy repeated after treatment

Anticoagulation should not affect risk stratification or workup