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Evaluation of Microscopic Hematuria

Evaluation of Microscopic Hematuria. Alon Z. Weizer, MD, MS Division of Urologic Oncology Department of Urology University of Michigan. Microscopic Hematuria (MH). Objectives of Presentation Appreciate the importance & possible etiologies of MH

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Evaluation of Microscopic Hematuria

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  1. Evaluation of Microscopic Hematuria Alon Z. Weizer, MD, MS Division of Urologic Oncology Department of Urology University of Michigan

  2. Microscopic Hematuria (MH) • Objectives of Presentation • Appreciate the importance & possible etiologies of MH • Understand the proper determination of MH • Consider the steps in evaluation of MH • Articulate recommended follow-up in cases of MH with negative initial evaluation

  3. Why Evaluate MH? • Gross hematuria is very often an indication of disease • Although less ominous, MH also can be an indication of disease • While many of these abnormalities are minor, some are significant and/or life-threatening

  4. Possible Causes • Life-Threatening • Cancer • Renal parenchyma • Renal pelvic • Ureteral • Bladder • Prostatic • Urethral • Penile • AAA • Require Treatment • Calculi • Vesico-ureteralreflux • Infection • Ureteralobstruction • Symptomatic urethral obstruction • Renal parenchymaldisease • Symptomatic BPH • Renal artery stenosis • Renal vein thrombosis

  5. Urothelial Tumors

  6. Renal Mass

  7. Prevalence of MH • 0.2% to 16% in population studies • 2.5% to 21% in screening programs • 13% to 21% in men >60 years old • Likelihood of finding etiology of MH varies with risk • Low risk: Significant finding <5% • High risk: Significant finding >50%

  8. Updated Clinical Guidelines • AUA Best Practices Panel: • Urology, Nephrology, Family Medicine, Radiology • Literature review & expert opinion • Critique of document by other physicians • Approval of AUA

  9. Purpose of Recommendations • Resource for urologists & PCPs • Directed towards evaluation of asymptomatic MH in adults • Not meant to address: • Screening for hematuria • Gross hematuria • Symptomatic hematuria • Pediatric age group

  10. Determination of MH • Freshly voided, clean-catch, midstream specimen • Dipstick for Hb is screening test only • 95% sensitive, but only ~80% specific • In population with 10% hematuria, PPV of Dipstick is only 35% • Positive Dipstick must be confirmed by microscopy (>3 RBC/hpf)

  11. Determination of MH • >3 RBC/hpf is standard criterion • 1 to 2 RBC/hpfdoesn’t require evaluation in most • However, it might if risk factors present • Just 1 specimen with hematuriashould prompt evaluation • Old rule: 2 of 3 properly collected specimens was standard criterion

  12. Why the Change? • There is substantial evidence that MH caused by a serious underlying condition can be highly intermittent • Studies that evaluated patients after 1 positive sample, rates of malignancy in most were over 2% • Non-life-threatening diagnoses that would benefit from active management or follow-up are frequently found

  13. Risk Factors for Significant Disease • Smoking history • Occupational exposure to chemicals or dyes • Benzenes or aromatic amines • History of analgesic abuse • Age >40 years • Significant urological history • Previous gross hematuria • Irritative voiding symptoms • Urinary tract infection • Prior pelvic radiation

  14. Determination of MH • Hematuria cannot be determined in presence of squamous epithelial cells • These cells may indicate contamination from source outside urinary tract • Frequent in women • Difficultly obtaining perfect clean-catch specimen • Occasionally in men • Phimosis (cells from foreskin) • Squamous cells may be present in bladder urine

  15. Determination of MH • If there appears to be hematuria, but squamous cells are present, then get catheterized specimen • Most common reason for “unnecessary” hematuria referral = contaminated specimen • Conversely, urine w/o RBCs is adequate for determination, even if there are squamous cells

  16. Glomerular Hematuria • Origin of blood from renal parenchymal disease can be suggested by UA • Dysmorphic RBCs (variable size & shape w/irregular outline) → sensitive • Plain microscopy, or may need inverted phase-contrast microscopy

  17. Asymptomatic MH History and Physical Examination Rule Out Benign Causes: Menstruation Vigorous Exercise Sexual Activity Viral Illness Trauma Infection Resolved after Tx or delay Persistent No Evaluation Evaluation Required

  18. Evaluation: H&P • Gross or microscopic? • Gross more often assoc w/significant disease • Initial, terminal or total? • Initial = urethra, terminal = bladder neck/prostate • Pain, dysuria, bladder irritability • Suspect infection or obstruction • Anti-coagulated • Still require evaluation

  19. Evaluation: H&P • Sickle cell, diabetes • Family or personal history of calculi, PCKD, other GU/Neph diseases • Trauma, physical or sexual activity • Tobacco use, occupational exposure • Association with menses • Fever, palpable mass, atrial fibrillation, visible blood at meatus, CVAT

  20. Confirmed MH (obtain Serum Cr) Suggestion of Primary Renal Disease? Proteinuria* (> 500 to 1000 mg / day) Dysmorphic RBCs or RBC casts Elevated Serum Cr Yes No Urology Referral + Concurrent Nephrology Evaluation Urological Evaluation * Dipstick >1+ for protein prompts 24 hr urine

  21. Purpose of Urological Eval • Upper tract imaging • Diseases of the kidney & ureter • Most commonly &/or significantly: • Calculi • Urothelial lesions • Obstruction • Renal masses • Cystoscopy • Diseases of the bladder & urethra • Most commonly &/or significantly: • Bladder cancer • BPH • Urethral strictures

  22. Urological Evaluation for Asymptomatic MH Upper Tract Imaging Multi-phasic CT urography Alternative1 : MR urography Alternative 2: RPGs w/MRI Cystoscopy In patients ≥35 years & Patients w/RFs regardless of age (Discretionary: those <35 w/o RFs) Abnormal? Abnormal? Yes Yes Treat No No Consider Urine Cytology Follow-up Protocol

  23. Imaging Modalities • Computed Tomography • Best modality for characterization of small renal masses • More widely available & less expensive than MRI • Best modality for calculi, renal and perirenal infection & associated complications • Sensitivity for urothelial lesions not defined with certainty, but thought to be good with “urography” technique

  24. Calculus

  25. Renal Mass

  26. CT Urogram

  27. Other Options • MR urography • Pregnancy, patients with iodinated contrast allergy • Risk of nephrogenic systemic fibrosis in patients with renal insufficiency • Retrograde pyelograms combined w/magnetic resonance imaging

  28. Follow-Up Protocol • UA at 12 & 24 months • If negative for 2 consecutive years, then D/C • If persistent asympomatic MH, repeat urological evaluation w/in 3 – 5 years • If gross hematuria or new voiding sx, repeat urological evaluation

  29. Before Urological Referral • Determine if this is real MH • >3 RBC/hpf • Catheterized urine if squamous cells • Exclude benign causes w/H&P • Likely glomerular → Refer to neph, too • Obtain serum Cr • Order imaging

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