Family Medicine - Hematuria

Front 1

What is hematuria?

Back 1

A.Significant Hematuria: >3-5 Red Blood Cells/HPF

Front 2

What risk factors suggestive of significant causes of Hematuria

Back 2

A.Tobacco abuse
B.Occupational exposures (leather dye, rubber, tire)
1.Benzenes
2.Aromatic amines
C.Gross Hematuria
D.Age over 40 years
E.Voiding symptoms suggestive of irritation
F.Urinary Tract Infection history
G.Analgesic overuse
H.Pelvic irradiation history

Front 3

What is the most common cause of hematuria under the age of 40?

Back 3

a.Genitourinary infection
b.Nephrolithiasis

Front 4

What is the most common cause of hematuria over the age of 40?

Back 4

2.Over age 40 yearsa.Urinary tract cancer (up to 10% of cases)
b.Prostatic Disease

Front 5

What are causes of hematuria and pain?

Back 5

1.Nephrolithiasis
2.Renal Vein Thrombosis
3.Renal Artery Occlusion
4.Renal Cancer

Front 6

What is nephrolithiasis?

Back 6

A.Stone formation is inhibited by Citrate
B.Women have much higher levels of citrate than men
C.Low citrate levels are related to most stone forms

Front 7

What are causes of hematuria with dysuria?

Back 7

1.Hemorrhagic cystitis (Urinary Tract Infection)
2.Prostatic infection
3.Bladder stones

Front 8

What are causes of hematuria with a history of trauma?

Back 8

1.Urethral disruption (seen in pubic Fracture)
2.Bladder injury (seen in Pelvic Fracture)
3.Renal Laceration or rupture

Front 9

What are more benign causes of hematuria?

Back 9

A.Bladder and Urethra Disease1.Inflammation of the Urethral trigone
2.Urethral polyp or Bladder neck polyp
3.BladderVarices
4.Trabeculated Bladder
5.Urethritis

B.Kidney and ureter disease1.Pelvic Kidney
2.Renal cyst
3.Duplicate collecting system
4.Scarred Kidney
5.Calyceal diverticulum

C.Prostate Disease1.Prostatic stone

D.Miscellaneous1.ExerciseHematuria

Front 10

What are some systemic causes of hematuria?

Back 10

A.Cardiovascular and hematologic causes
1.Endocarditis

B.Rheumatologic Causes
1.Systemic Lupus Erythematosus
2.Vasculitis

C.Medications
1.See Medication Causes of Hematuria
2.Interstitial Nephritis (Gold, Penicillamine, NSAIDs)
3.Warfarin (if associated with urologic anomaly)

D.Infections
1.Acute Post-Streptococcal Glomerulonephritis
2.Henoch-Schonlein Purpura
3.Tuberculosis

Front 11

What are some causes of hematuria?

Back 11

A.See Adult Microscopic Hematuria Causes
B.See Medication Causes of Hematuria
C.Athletes with Running trauma (March Hematuria)1.Hematuria transiently related to activity
2.Recheck Urinalysis in 2 weeks

Front 12

What is the protocol for hematuria?

Back 12

A.Consider non-urinary source (e.g. vagina, rectum)

Front 13

If you get a RBC > 3/hpf with bacteriuria and urine nitrate?

Back 13

1.Treat as Urinary Tract Infection
2.Repeat Urinalysis in 6 weeks
a.No urine blood: Observe
b.Hematuria: Evaluate as isolated Hematuria below

Front 14

What if you get a RBC > 3/hpf with renal disease signs?

Back 14

1.Signs suggestive of renal etiology
a.Proteinuria (1+ or greater on dipstick)
b.Serum Creatinine elevated
c.Dysmorphic Red Blood Cells or Red cell casts
i.Suggests glomerular cause
ii.No dysmorphic cells suggests interstitial cause

2.Collect 24 hour urine for protein and Creatinine
3.Obtain nephrology consultation

Front 15

What should you do if you have Hematuria and Urine RBC > 3/hpf alone (isolated Hematuria)

Back 15

1.Suggests urologic cause (non-renal) a.Cancer in 20% of gross, <5% of occult bleeding
b.Isolated Hematuria may occur in 20% of renal causes

2.Helical CT Urograma.See diagnosis below

3.Obtain urine cytology (3 first morning voids)
4.Eliminate benign causes
a.Menstruation
b.Strenuous Exercise or sexual activity
c.Viral illness
d.Trauma
e.Genitourinary infection

5.Consider risk factors above
6.Obtain Urology consultation and cystoscopy
7.If evaluation normal
a.Obtain clotting values and hematologic tests
b.Consider hematology consultation
c.If evaluation negative i.No further work-up needed
ii.Exceptions: Gross Hematuria, Symptoms

Front 16

What should you do if you have persistent idiopathic microscopic hematuria?

Back 16

1.Repeat Urinalysis every 6 months
2.Repeat urine cytology every 6 months
3.Repeat cystoscopy every year

Front 17

What are signs of glomerular disease?

Back 17

`1.Signs of glomerular diseasea.
Urine brown (Coca-Cola color)
b.Microscopyi.Red Blood Cell casts
ii.Dysmorphic Red Blood Cells

Front 18

What are signs of extraglomerular disease?

Back 18

clots of blood

Front 19

What type of cancer and how would you evaluate for this if you see hematuria?

Back 19

1.Obtain three serial first-morning specimens
2.Evaluate for transitional cell cancer

Front 20

How should you test for suspected glomerulonephritis?

Back 20

Collect 24 Hour Urine Protein and Creatinine Clearance

Front 21

What is the 3 Glass Test urinalysis?

Back 21

1.Glass 1: Initiation of urine streama.
Hematuria in Glass 1 only suggests Urethral source

2.Glass 2: Midstream urinea.
Hematuria in all glasses suggests Bladder or renal

3.Glass 3: Termination of urine streama.
Hematuria in Glass 3 only suggests Prostate source

Front 22

A patient performs the 3 glass test and in the 3rd glass you find hematuria, what is the possible Dx?

Back 22

prostate source

Front 23

On a 3 glass hematuria test you find hematuria in all glasses, what is the possible Dx?

Back 23

bladder or renal cause

Front 24

On a 3 glass hematuria test you find hematuria only in glass I, what is the possible Dx?

Back 24

urethral source

Front 25

What is the preferred imaging study for hematuria?

Back 25

helical CT urogram

Front 26

What can an ultrasound tell you?

Back 26

1.Defines anatomy
2.Signs of glomerular disease and renal cysts
3.CT Urogram is usually preferred over Ultrasound

Front 27

Why would you perform a intravenous pyelogram?

Back 27

Suspected Nephrolithiasis

Front 28

Why would you perform cystoscopy?

Back 28

1.Extraglomerular source of Hematuria

Front 29

When would you perform an MRI with hematuria?

Back 29

1.Indicated where CT Urogram is contraindicated (e.g. Pregnancy, Children)
2.Identifies urothelial cancer, Nephrolithiasis and renal tumors

Front 30

What is microscopic hematuria?

Back 30

more than 3 RBCs per HPF

Front 31

If a person has flank pain radiating into the groin what is this?

Back 31

kidney stone

Front 32

What 2 diseases is fever associated with?

Back 32

pyelonephritis
or
renal cell carcinoma

Front 33

In 90% of patients with renal cell carcinoma what is sign present?

Back 33

hematuria

Front 34

What chemotherapuetic agent particulary causes hematuria?

Back 34

cyclophosphamide

Front 35

What 2 meds can have a side effect of red urine?

Back 35

pyridium and rifampin

Front 36

What 12 or so causes that can make a person's urine red?

Back 36

1.Myoglobinuria
2.Hemoglobinuria
3.PhenolphthaleinLaxatives
4.Phenothiazines
5.Porphyria
6.Rifampin
7.Pyridium
8.Bilirubinuria
9.Phenytoin
10.Pyridium
11.Red diaper syndrome
12.Foods (Beets, Blackberries, Rhubarb)

Front 37

A 43 yr old female presents with costovertebral angle tenderness what is the likely diagnosis?

Back 37

pyelonephritis