Evaluation of Hematuria In The Primary Care Setting Randall B. Meacham, MD Objectives: 1. Discuss potential etiologies of hematuria 2. Implement a plan for evaluating the patient with gross or microscopic hematuria 3. Understand when it is appropriate to refer a patient with hematuria for care by a specialist 4. Structure a plan for followup for the patients with hematuria 1
Prevalence of Microscopic Hematuria In 6 population based studies, incidence ranged from 0.18% to 16.1% 20% of Urology clinic visits in the Kaiser Permanente system Definition of Hematuria Gross: Visible blood in the urine Microscopic: 3 or more RBC/hpf Absence of a clear benign cause Positive dipstick does NOT constitute MH AUA Best Practice Guidelines, 2012 2
Positive Dipstick UA Indicates the need for performance of a microscopic UA Limited specificity (65 to 99%) for 2 to 5 RBC / HPF Factors that can cause a falsepositive result on a dipstick test include hemoglobinuria, myoglobinuria, concentrated urine Most Common Causes of Hematuria UTI BPH Nephrolithiasis Genitourinary cancer 3
Other Causes of Hematuria Radiation cystitis Arteriovenous malformation Medical renal disease Trauma Renal cystic disease Exerciseinduced hematuria Coagulopathy Benign familial/essential hematuria Papillary necrosis Nonbloody red urine Beets Blackberries Drugs (pyridium) 4
Odds of Finding Significant Pathology 4090% of gross hematuria 510% of microscopic hematuria At least 40% of the time no etiology is found for asymptomatic microscopic hematuria History of Present Illness Dysuria? Frequency? Menstruation? Previous episodes, workup 5
Medications Pyridium Analgesic abuse Social History Smoking Exposure to dyes, chemicals Exercise patterns 6
Physical Examination Age (cancer risk) Pain suprapubic, flank (infection) DRE (BPH) Laboratory Evaluation UA, microscopy Urine culture CBC Serum Creatinine 7
Evaluation of Microscopic Hematuria MH Repeat UA after treatment of other cause(s) Release from Care Treatment Followup as indicated by diagnosis. Reevaluate for MH after resolution of identified condition Assess for other potential causes (infection, menstruation, recent urologic procedures) Renal Function Testing, Cystoscopy, * Imaging (CTU) Follow up with at least one UA/micro yearly for at least 2 years Release from Care Consider nephrologic evaluation if proteinuria, acanthocytes, red cell casts, renal failure Follow persistent MH with annual UA, consider nephrologic eval. Repeat anatomic eval within 35 yrs. Or sooner if clinically indicated Cystoscopy optional in nonhigh risk patients < 35 y/o * High Risk Patients Age > 35 years Occupational exposure to chemicals or dyes (benzenes of aromatic amines) History of gross hematuria History of irritative voiding symptoms History of pelvic irradiation Analgesic abuse History of UTI History of urologic disorder or disease 8
Best Upper Tract Study CT Urogram 3 phases Noncontrast to r/o calculi Contrast to evaluate parenchyma Excretion phase to evaluate GU lining Lower Tract Evaluation Depends on age and risk factors Cystoscopy (CT misses many bladder tumors) Is typically an office procedure 9
Case Studies 42 yo mother of oneyearold twins noted to have 510 RBC s per HPF on 2 UAs History and Physical Exam No dysuria/frequency/pain No h/o respiratory infection or stones No history of coagulopathy/non menstrual No history of radiation or surgery x c/s Nonsmoker no chemical exposure 10
Laboratory Evaluation UA shows RBC s No cellular casts or proteinuria CBC normal Creatinine normal No UTI on culture Now what? Evaluation of Microscopic Hematuria MH Repeat UA after treatment of other cause(s) Release from Care Treatment Followup as indicated by diagnosis. Reevaluate for MH after resolution of identified condition Assess for other potential causes (infection, menstruation, recent urologic procedures) Renal Function Testing, Cystoscopy, * Imaging (CTU) Follow up with at least one UA/micro yearly for at least 2 years Release from Care Consider nephrologic evaluation if proteinuria, acanthocytes, red cell casts, renal failure Follow persistent MH with annual UA, consider nephrologic eval. Repeat anatomic eval within 35 yrs. Or sooner if clinically indicated Cystoscopy optional in nonhigh risk patients < 35 y/o * 11
Upper and Lower Tract Imaging US showed no abnormality of the kidneys Bladder US was unclear Now what? Outcome: No additional evaluation performed. Patient developed gross hematuria 6 months later. Ultimately was found to have bladder cancer on cystoscopy and required cystectomy 12
Case 2 59 yo male Gross hematuria with flank pain Now what? History and Physical No dysuria/frequency/pain No h/o respiratory infection No history of coagulopathy No history of radiation or surgery Nonsmoker no chemical exposure Now what? 13
Laboratory Evaluation UA shows RBC s CBC normal Creatinine normal No UTI on culture PSA done 3 months ago: 2.3ng/dl Now what? Evaluation of Microscopic Hematuria MH Repeat UA after treatment of other cause(s) Release from Care Treatment Followup as indicated by diagnosis. Reevaluate for MH after resolution of identified condition Assess for other potential causes (infection, menstruation, recent urologic procedures) Renal Function Testing, Cystoscopy, * Imaging (CTU) Follow up with at least one UA/micro yearly for at least 2 years Release from Care Consider nephrologic evaluation if proteinuria, acanthocytes, red cell casts, renal failure Follow persistent MH with annual UA, consider nephrologic eval. Repeat anatomic eval within 35 yrs. Or sooner if clinically indicated Cystoscopy optional in nonhigh risk patients < 35 y/o * 14
Upper and Lower Tract Imaging CT scan abd shows L kidney stone 1x1cm Cytologies are atypical Now what? What Happened Pt had his kidney stone treated with shockwave lithotripsy Meanwhile a bladder tumor grew in his bladder for a year One year later, he underwent cystoscopy, biopsy, and eventually cystectomy 15
Case 3 52 year old male noted total gross, painless hematuria at completion of a 2 hr. totally in your face, badass, that s right who s your daddy now? mountain bike ride. No prior history of hematuria, no other GU complaints. Only one episode of hematuria. History and Physical Moderately overweight otherwise completely benign Medications include only Viagra, Lipitor and Magnum Man (purchased via the internet) No history of coagulopathy No history of radiation or surgery No chemical exposure Smoked a little reefer in college Feels fine not enthusiastic about additional screwing around with this 16
UA unremarkable HCT 39% Creatinine 0.9 Now what? Evaluation of Microscopic Hematuria MH Repeat UA after treatment of other cause(s) Release from Care Treatment Followup as indicated by diagnosis. Reevaluate for MH after resolution of identified condition Assess for other potential causes (infection, menstruation, recent urologic procedures) Renal Function Testing, Cystoscopy, * Imaging (CTU) Follow up with at least one UA/micro yearly for at least 2 years Release from Care Consider nephrologic evaluation if proteinuria, acanthocytes, red cell casts, renal failure Follow persistent MH with annual UA, consider nephrologic eval. Repeat anatomic eval within 35 yrs. Or sooner if clinically indicated Cystoscopy optional in nonhigh risk patients < 35 y/o * 17
Upper and Lower Tract Evaluation Cystoscopy? Thank You 18