genitourinary disorders
Isolated Hematuria
Evaluation of Isolated Hematuria
History of present illnessincludes duration of hematuria and any previous episodes. Urinary obstructive symptoms (eg, incomplete emptying, nocturia, difficulty starting or stopping) and irritative symptoms (eg, irritation, urgency, frequency, dysuria) should be noted. Patients should be asked about the presence of pain and its location and severity and whether they have vigorously exercised. should seek symptoms of possible causes, including joint pain and rashes (connective tissue disorder), and hearing loss or ocular manifestations ( Alport Syndrome , also called Alport syndrome). Presence of fever, night sweats, or weight loss should also be noted. should include questions about any recent infections, particularly a sore throat that may indicate a group A beta-hemolytic streptococcal infection. Conditions known to cause urinary tract bleeding (particularly Urinary Calculi , Family history should identify relatives with known Autosomal Dominant Polycystic Kidney Disease (ADPKD) , a Vital signs should be reviewed for fever and Hypertension . The heart should be auscultated for murmurs (suggesting Infective Endocarditis ). The abdomen should be palpated for masses; flanks should be percussed for tenderness over the kidneys. In men, a digital rectal examination should be done to check for prostate enlargement, nodules, and tenderness. The face and extremities should be inspected for edema (suggesting a glomerular disorder), and the skin should be inspected for rashes (suggesting Overview of Vasculitis , The following findings are of particular concern: Gross hematuria and concurrent proteinuria Persistent microscopic hematuria, especially in older patients Age>50 Hypertension and Systemic symptoms (eg, fever, night sweats, weight loss) Clinical manifestations of the various causes overlap significantly, so urine and often blood tests are required. Depending on results, imaging tests may then be needed. However, some clinical findings provide helpful clues (see table Some Common Specific Causes of Hematuria ). Blood clots in urine essentially rule out a glomerular disorder. Glomerular disorders are often accompanied by edema, hypertension, or both; symptoms may be preceded by an infection (particularly a group A beta-hemolytic streptococcal infection in children). Calculi usually manifest with excruciating, colicky pain. Less severe, more continuous pain is more likely to result from infection, cancer, Autosomal Dominant Polycystic Kidney Disease (ADPKD) , Urinary irritative symptoms suggest bladder or prostate infection but may accompany certain cancers (mainly bladder and prostate). Urinary obstructive symptoms usually suggest prostate disease. An abdominal mass suggests polycystic kidney disease or Renal Cell Carcinoma . A family history of nephritis, Sickle Cell Disease or trait, or polycystic kidney disease suggests that as a cause. Travel to Africa, the Middle East, or India suggests the possibility of Schistosomiasis . Systemic symptoms (eg, fever, night sweats, weight loss) may indicate cancer or subacute infection (eg, tuberculosis [TB]) or an autoimmune (connective tissue) disorder. On the other hand, some common findings (eg, prostate enlargement, excessive anticoagulation), although potential causes of hematuria, should not be assumed to be the cause without further evaluation. Before testing proceeds, true hematuria should be distinguished from red urine by urinalysis. In women with vaginal bleeding, the specimen should be obtained by straight catheterization to avoid contamination by a nonurinary source of blood. Red urine without red blood cells (RBCs) suggests myoglobinuria or hemoglobinuria, Overview of Porphyrias , or ingestion of certain drugs or foods. Generally, the presence of hematuria should be confirmed by testing a 2nd specimen. Presence of casts, protein, or dysmorphic RBCs (unusually shaped, with spicules, folding, and blebs) indicates a Overview of Glomerular Disorders . White blood cells or bacteria suggest an infectious etiology. However, because urinalysis shows predominantly RBCs in some patients with 35 (including children) have only microscopic hematuria and no urine findings suggesting a glomerular disorder, no clinical manifestations suggesting a cause, no risk factors for cancer, and an identified benign cause (eg, infection, mild trauma), they can be observed, with urinalysis repeated every 6 to 12 months. If a benign cause is not evident or hematuria is persistent, testing is indicated ( General reference ), beginning with ultrasonography or CT with contrast, sometimes followed by cystoscopy. Patients<50 with gross hematuria or unexplained systemic symptoms require ultrasonography or CT of the abdomen and pelvis. nitrogen, serum creatinine, and electrolytes; doing a urinalysis; and periodically determining the urine protein/creatinine ratio. Further evaluation of a glomerular disorder may require serologic tests, Renal biopsy , or both. 35 require Cystoscopy , as do patients who are 1.Barocas DA, Boorjian ST, Alvarez RD, et al: Microhematuria: AUA/SUFU guideline.J Urol204(4):778-786, 2020. doi: 10.1097/JU.0000000000001297 