© The Canadian Journal of Urology™; 19(Supplement 1); October 2012
Sing AND Singal
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Smaller stones that reside in the kidney are usually
asymptomatic, and microscopic hematuria may be the
only manifestation. Larger stones, including staghorn
calculi, may present with gross hematuria. Staghorn
calculi may be associated with the presence of UTIs
when the urine is infected with a urease-producing
organism such as Proteus. Hematuria associated with
the acute onset of lateralizing flank pain is the classic
presentation of a stone that moves into the ureter.
Malignancies
Urological malignancies are potentially serious. Ahigh
index of suspicion and careful evaluation of patients
with hematuria will ensure that any malignancy
is diagnosed quickly. With the widespread use of
abdominal ultrasound, most renal cell carcinomas are
found as an incidental mass at the time of imaging.
Microscopic hematuria is common in these situations.
Gross hematuria is not as common, but it may be seen
if the patient has a larger mass located more centrally
in the kidney.
Urothelial carcinoma arises from the lining of the
collecting system. Gross hematuria tends to be the
most common symptom with this type of tumor.
Patients who have a tumor that arises from the renal
pelvis or ureter may present with flank pain, and
they may note the passage of “worm-like clots” on
micturition. Lesions arising from the bladder often
cause no pain, but patients with these lesions may
have large blood clots when they urinate.
Although incidental microscopic hematuria may
be present when prostate cancer is diagnosed, this
hematuria is more likely due to benign prostatic
hyperplasia (BPH) rather than the cancer. Typically,
prostate cancer does not cause hematuria unless it is
in more advanced stages. In advanced or metastatic
prostate cancer, hematuria is often associated
with other constitutional and obstructive urinary
symptoms. Successful treatment of prostate cancer
will often eliminate or significantly reduce the severity
of any hematuria.
BPH
BPH commonly and progressively afflicts men as they
age. While the classic patient presentation is usually
that of lower urinary tract obstructive or irritative
symptoms, hematuria is also common. BPHmay, in fact,
be the most common cause of microscopic hematuria
in men. Less commonly, BPHmay be the sole cause of
gross hematuria and clot retention. Adiagnosis of BPH
can be made only after full urological evaluation and
exclusion of other causes of hematuria.
Nephropathies and nephritis
Themedicalcausesofhematuriashouldnotbeoverlooked.
This is particularly true in the presence of microscopic
hematuria in children. Patients with nephropathies
and nephritis may present with hypertension, edema,
and renal insufficiency, and urine tests may reveal
the presence of proteinuria and RBC casts. When
appropriate, the primary care physician should consider
consulting a nephrologist. Since smoking can lead
to immunoglobulin A (IgA) glomerulonephritis and
microscopic hematuria, it is always important to ask
patients about smoking when taking a clinical history.
Patient management
In the physician’s office, hematuria can be identified
by a patient’s clinical history—a complaint of gross
hematuria—and/or findings from a routine urine
dipstick test. Physicians should take a thorough
clinical history. They should assess a patient for factors
placing them at higher risk of significant urological
disease. These include age older than 40 years; past
or current analgesic abuse, smoking, or exposure to
chemicals or dyes (benzenes or aromatic amines); or
history of pelvic irradiation, gross hematuria, irritative
voiding symptoms, or UTIs.
5
The patient’s current
medications or prior urinary tract interventions might
be linked to the bleeding, see Table 2.
To do a urine dipstick test, the patient should
be instructed to provide a fresh, midstream urine
sample, and the sample should not be left for more
than 2 hours at room temperature before it is tested.
TABLE 2.
Medications and interventions associated
with hematuria
Medications
•
Penicillins, aminoglycosides, cephalosporins
•
Amitriptyline
•
Cyclophosphamides
•
NSAIDs
•
Rifampin
Interventions
•
Recent surgery for urolithiasis
•
Urinary tract stenting
•
Transurethral procedures of the lower urinary tract
•
Transrectal biopsy of the prostate
•
Genitourinary radiation therapy
•
Bacillus Calmette-Guerin installations for bladder
cancer
•
Bladder instillations for interstitial cystitis
