© The Canadian Journal of Urology™; 19(Supplement 1); October 2012
Address correspondence to Dr. Rajiv K. Singal, Department
of Urology, Toronto East General Hospital, 840 Coxwell
Avenue, Suite 218, Toronto, Ontario M4C 5T2 Canada
What is significant hematuria for the primary
care physician?
Roland I. Sing, MD, Rajiv K. Singal, MD
Division of Urology, Department of Surgery, University of Toronto-Toronto East General Hospital, Toronto, Ontario, Canada
SINGRI,SINGALRK.Whatissignificanthematuriafor
theprimarycarephysician?
CanJUrol
2012;19(
Suppl 1):
36-41.
Hematuria is a common finding in primary care practice.
Causes of significant hematuria include urinary tract
infection, urolithiasis, malignancies, benign prostatic
hyperplasia, and nephropathies. Hematuria is identified
by taking a patient history and by performing a routine
urine dipstick test. If a patient has a history of gross
hematuria and/or a positive urine dipstick test, he or she
should then have a microscopic urinalysis. The primary
care physician can order ancillary tests such as laboratory
tests to assess renal function, and possible imaging tests
such as ultrasound, computed tomography urography,
or magnetic resonance urography. The patient may
be referred to a nephrologist or urologist for further
assessment if required. Cystoscopy may be considered.
Even if the patient has a negative work up, guidelines
recommend that primary care physicians follow the patient
semi-annually for 3 years.
Key Words:
referral,
hematuria, primary care,
laboratory tests, imaging, cystoscopy
What is significant hematuria?
When confronted with a patient with hematuria, a
clinician must establish whether the hematuria is
clinically significant. This will allow a primary care
physician and/or specialist to begin an appropriate
work up in these patients. Gross hematuria should
always be considered significant, and it may also
be regarded as a sign of malignancy until proven
otherwise. It is important that the patient’s clinical
history corroborates that the blood originates from
the urinary tract. A history of “red urine” does not
always equate with the presence of blood, see Table 1.
2
Patients should be questioned to provide a complete
clinical history, possiblywith a familymember present.
Questioning someone who witnessed the patient’s
hematuria may be helpful. The passage of blood clots
during urination is a good confirmatory detail. If the
patient is female, a gynecological history may help
rule out hematuria arising from vaginal bleeding. If
36
Introduction
Hematuria is a clinical finding that is commonly
encountered by primary care physicians and urologists.
Although it is common, it should not be ignored,
because roughly 4% of patients with microscopic
hematuria and up to 40% of patients with gross
hematuria could be harboring a malignancy.
1
Those
percentages represent a significant number of patients
in a busy clinical practice. Practicing physicians will
generally have at least one and perhaps several patients
whose lives are changed because their hematuria was
investigated and evaluated. Therefore, it is important
to effectively and efficientlymanage patients who have
hematuria.
