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Approach to Hematuria

Approach to Hematuria. Resident teaching rounds Steve Radke :) July 30, 2003 Reference: Cohen et al. NEJM 348;23 June 5, 2003. P 2330-2338. Hematuria. Clinical case Classification DDx History, Physical Investigations Approach. Clinical Case . 48 year old healthy female

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Approach to Hematuria

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  1. Approach to Hematuria • Resident teaching rounds • Steve Radke :) • July 30, 2003 • Reference: Cohen et al. NEJM 348;23 June 5, 2003. P 2330-2338.

  2. Hematuria • Clinical case • Classification • DDx • History, Physical • Investigations • Approach

  3. Clinical Case • 48 year old healthy female • 5 rbc/hpf • Doctor….what’s going on?

  4. Classification • Gross hematuria • Microscopic hematuria • >= 2 rbc/hpf • True • Pseudohematuria • menses • dyes • beets, candy, juices • meds (e.g.. rifampin) • myoglobinuria, hemoglobinuria due to hemolysis

  5. Classification • Glomerular • Nonglomerular • upper urinary tract • lower urinary tract • Diagnostic

  6. DDx (without the minutia) • Origin < 50 yo > 50 yo • Glomerular IgA nephropathy IgA nephropathy • Nonglomerular • Upper tract nephrolithiasis nephrolithiasis • pyelonephritis renal-cell ca • polycystic kidney polycystic kidney • Lower tract cystitis, prostatitis, urethritis • benign bladder tumors bladder ca • bladder ca prostate ca • prostate ca benign bladder • tumors

  7. History • age • timing • urinary sxs • STI • flank pain • trauma, exercise • obstructive sxs • RFs: smoking, chemicals, radiation

  8. Physical exam • B.P. • abdominal exam • DRE

  9. Investigations - glomerular • Urine dip • protein, WBC, nitrites • Urine microscopy • rbc count • wbc count • red cell casts • If Red Cell Casts, Protein or Increased Cr • ---> glomerular origin

  10. Investigations - upper tract • U/S • limited in detecting solid tumors <3cm • IVP • radiographic contrast die exposure • less sensitive and specific than U/S • sometimes can not differentiate solid vs cystic masses • CT • with and w/o contrast • preferred method

  11. Investigations - lower tract • Cystoscopy • Urine Cytology • less sensitive than cystoscopy, but • more specific • AM void samples x 3

  12. The Approach • Microscopic hematuria • urine dipstick +ve • repeat urine dipstick -ve w/u ends unless • (several days later) RF for bladder ca • +ve • Gross hematuria microscopy • red cell casts no red cell casts • glomerular hematurianonglomerular hematuria

  13. The Approach • glomerular hematuria • NO protein or +ve protein or • renal insufficiency renal insufficiency • periodic medical follow-up Nephrology referral • monitor for proteinuria or for renal biopsy • renal insufficiency • (q 6-12 months)

  14. The Approach • nonglomerular hematuria • CT +ve refer based • (or U/S) on lesion • -ve • urine cytology +ve cystoscopy • -ve • >= 50 or <50 and • RF for bladder Ca or no RF for bladder Ca • gross hematuria • cystoscopy w/u ends (yearly urinalysis)

  15. Take home messages • >50 yo R/o Ca • do casts • CT (not u/s or ivp)

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