Hematuria

Microscopic hematuria algorithm, from AUA Guidelines

Assessing hematuria risks

Epidemiology

Risk factors

Hematuria workup

Risk Groups

Risk Needs all criteria? Age Smoking
(packyears)
# RBC
(UA x1)
Urothelial cancer
risk factors*
Prior hematuria Probability malignant cause Recommendations
Low Yes Women < 50
Men < 40
< 10 3-10 None No 0.2-0.5% Repeat UA in 6mo, OR...
Cysto + renal US
Intermediate No Women 50-59
Men 40-59
10-30 11-25 1+ Persistent 3-10 RBC 1.3-1.6% Cysto + renal US
High No 60+ > 30 > 25 - Gross 10.8-11.1% Cysto + CTU

*Risk factors include increased age, male, prior smoking, irritative voiding symptoms, prior pelvic radiation, prior cyclophosphamide, history urothelial cancer or Lynch syndrome, prior occupational exposures, and chronic indwelling foreign body

Considerations

Workup components

Follow-up

Hematuria grading scale, from Lee 2013

Glomerular causes of hematuria, from Campbell's

Management

Initial Evaluation of Gross Hematuria

BPH

Prostate Cancer

Urethrorrhagia

Upper tract causes

Random causes of hematuria to rule out

Hemorrhagic Cystitis

Common Causes

Medical Management

Drug Mechanism Dosing Considerations Needs OR/Anesthesia?
Alum
Aluminum ammonium sulfate
Aluminum potassium sulfate
Protein precipitation
Vasoconstriction
1% solution (10g/L)
run at 200-300mL/hr
Success: 45-100%
Aluminum toxicity
No
Silver Nitrate Chemical coagulation 0.5-1% instilled for 10-20 minutes Check cystogram
(can cause obstruction if VUR)
No
Amicar
Aminocaproic acid
Inhibits fibrinolysis 200g/L
Give for 24hr after hematuria resolves
Success: up to 92%
Do not give if bladder clots present (causes clots to harden)
No
Formalin Cellular protein precipitation 1-4%
300mL or up to bladder capacity
10-15 minutes
Success: 80-90%
Bladder fibrosis
Ureteral strictures if VUR
Yes

Non-Medical Management

Treatment Tips
Hyperbaric Oxygen 100% O2 at 2-3 atm, 90 minutes, 30-40 sessions
Success: 80-90% response rate, but 5yr success only 27%
Side effects: claustrophobia (20%), otalgia (17%), seizures (rare)
Nephrostomy tubes Avoids bladder exposure to urokinase, allowing clots to form
Can be performed with ureteral coiling
Internal iliac artery embolization Can be performed unilaterally/bilaterally
Posterior occlusion results in significant gluteal pain
Success: up to 90%
Cystectomy + Urinary Diversion Complications in up to 80% if bladder not removed
High risk of complications

Different causes of urine color, from Campbell's

Proteinuria algorithm, from Campbell's

Things that look like hematuria but aren't hematuria

Non-hematuria findings

References