Hematuria

[Age]-yo [M/F] with PMH of ___, presenting with
____ days_ constant/intermittent progressively worsening/improving

  • CC: Hematuria (gross vs microscopic)

  • PP: Clots? dysuria, frequency, urgency, flank pain, fever, recent URI, trauma/Foley, prior episodes

  • PN: No abdominal pain, no CVA tenderness, no edema, no rash/joint findings

  • Pertinent SHx: tobacco , EtOH , drug use ___

  • Etiology: Glomerular vs Non-glomerular

  • Risk factors: Smoking, age >40, CKD, stones, malignancy hx, occupational exposures, anticoagulation

  • Initial DATA: UA (+RBCs), CBC, CMP, urine culture

  • Pending DATA: UPCR/UACR, CT abdomen/pelvis noncontras if Gross hematuria + flank pain, cloths, pain (rules out stones/clots/obstruction), CT urogram GROSS hematuria - pain-free OR microhematuria + high cancer risk . serologies if GN suspected

  • MEDS: AC/APT/NSAIDs

  • -- DDX: Stones, Hemorrhage (trauma), Infection, Inflammation (glomerulonephritis), Tumor, Thrombotic causes, and Exercise. “SHIITTE”

  • GLOMERULAR or NON-GLOMERULAR. Glomerular (Dysmorphic RBCs,RBC casts, Proteinuria, Dark “tea/cola-colored” urine, edema, HTN) Non-Glomerular (Normal-shaped RBCs,no acsts, minimal protein, bright blood, cloths, pain (stone,Inx), UTI-dysuria, frequency)

  • COURSE:

Plan

  • f/u UA with cx and UPCR ( proteinuria → glomerular )

  • trend RFP and CBC daily

  • Strict I&O

  • Watch for urinary retention/clot obstruction

  • Stop AC temporarily if uncontrolled gross hematuria

  • Type & screen (if gross hematuria/clots)

  • Consult Urology for Cystoscopy if High suspicion bladder Ca , clots, obstruction, known cancer history

  • consult Nephrology if glomerular pattern (proteinuria >1g, dysmorphic RBCs) and can order Workup: anti-GMB, anti-DNase/ASO, ANA, ANCA, C3, C4, cryo, Hep B/C, HIV

Hematuria Approach

Labs:

  • UA (≥3 RBCs/hpf = true hematuria) no RBCs → think Myoglobin (rhabdo) or Hemoglobin (hemolysis)

  • CK, hemolysis labs

  • Gross vs Microscopic -> Gross → higher malignancy risk → full workup, Microscopic (>3 RBC/hpf) → still significant

  • Glomerular vs Non-glomerular

    • Glomerular clues -> Dysmorphic RBCs, RBC casts, Proteinuria, (think-> IgA nephropathy (post-URI), PSG, Lupus nephritis, ANCA-associated vasculitis)

    • Non-glomerular clues -> normal RBC . clots, minimal protien (think -> stones, infx, tumor, truma)