HEMATURIA -

HEMATURIA

1️⃣ Definition

Hematuria = Presence of red blood cells (RBCs) in urine.

Types

Type	Definition	Clinical Significance
Gross hematuria	Visible red/brown urine	Always pathological until proven otherwise
Microscopic hematuria	≥3 RBCs per high-power field (HPF) in a properly collected urine sample	Needs evaluation based on risk stratification
Dipstick positive only	Heme positive but no RBCs on microscopy	Consider myoglobinuria/hemoglobinuria

As per American Urological Association (AUA):
≥3 RBC/HPF on microscopy = clinically significant microscopic hematuria.

2️⃣ Anatomy-Based Classification

Hematuria is best approached anatomically:

🔹 Glomerular

🔹 Non-glomerular (renal or post-renal)

🔹 Pseudohematuria

3️⃣ Glomerular Hematuria

Key Features

Feature	Suggests Glomerular
Dysmorphic RBCs	✔
RBC casts	✔
Proteinuria (>500 mg/day)	✔
Hypertension	Often present
Edema	May be present

Causes

Primary Glomerular Diseases

IgA nephropathy
Poststreptococcal glomerulonephritis
Membranoproliferative glomerulonephritis
Alport syndrome

Secondary Causes

Systemic lupus erythematosus
Vasculitis
Henoch-Schönlein purpura

4️⃣ Non-Glomerular Hematuria

Features

Feature	Suggests Non-Glomerular
Normal-shaped RBCs	✔
Clots in urine	✔ (never glomerular)
Minimal proteinuria	✔
Pain	Often present

Causes

A. Renal (Non-glomerular)

Renal cell carcinoma
Polycystic kidney disease
Papillary necrosis
Renal trauma
Pyelonephritis

B. Post-Renal (Ureter, Bladder, Prostate, Urethra)

Urolithiasis
Bladder cancer(painless hematuria)
Benign prostatic hyperplasia
UTI
Catheter trauma

5️⃣ Pseudohematuria

Urine red but no RBCs on microscopy.

Cause	Mechanism
Myoglobinuria	Rhabdomyolysis
Hemoglobinuria	Hemolysis
Rifampicin	Drug discoloration
Beetroot	Dietary

6️⃣ History –

Key Questions

✔ Painful vs painless
✔ Clots present?
✔ Recent infection?
✔ Anticoagulant use?
✔ Smoking history? (bladder cancer risk)
✔ Flank pain? (stones)
✔ Edema + HTN? (glomerular)

7️⃣ Physical Examination

BP (glomerular disease)
Edema
Abdominal mass
Prostate exam
Rash (vasculitis)
Joint pain (SLE)

8️⃣ Investigation Approach (Stepwise)

Step 1 – Confirm Hematuria

Urine microscopy (≥3 RBC/HPF)
Repeat sample

Step 2 – Determine Source

Finding	Interpretation
RBC casts	Glomerular
Dysmorphic RBC	Glomerular
Clots	Post-renal

Step 3 – Basic Labs

CBC
Creatinine
Urine protein
Urine culture
Coagulation profile

Step 4 – Imaging

🔹 Ultrasound KUB (first-line)

🔹 CT urography (if malignancy suspected)

🔹 MRI (selected cases)

Step 5 – Cystoscopy

Mandatory in:

Age >35–40 years
Smokers
Gross hematuria

Recommended by American Urological Association guidelines.

9️⃣ Risk Stratification (AUA Approach)

Risk	Features
Low	Young, no smoking
Intermediate	1–2 risk factors
High	Age >60, smoker, gross hematuria

High risk → CT urography + cystoscopy.

🔟 Special Situations

1️⃣ Hematuria in ICU

Common causes:

Catheter trauma
Anticoagulation
DIC
Sepsis-related AKI
Rhabdomyolysis

2️⃣ Hematuria + AKI

Think:

Rapidly progressive GN
Vasculitis
Lupus nephritis
Post-infectious GN

Urgent nephrology consult + biopsy.

3️⃣ Hematuria + Proteinuria

Assume glomerular until proven otherwise.

4️⃣ Terminal Hematuria

Blood at end of urination → bladder neck/prostate source.

5️⃣ Initial Hematuria

Blood at beginning → urethral source.

1️⃣1️⃣ Management Principles

D. Severe Gross Hematuria with Clots

Emergency management:

3-way Foley catheter
Continuous bladder irrigation
Manual clot evacuation
Urology consult