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BASICS

Description

  • Presence of blood in urine; either gross (visible) or microscopic (nonvisible).
  • Can be symptomatic or asymptomatic.

Epidemiology

  • Prevalence in children: gross hematuria 0.13%; asymptomatic microscopic hematuria (AMH) 0.4–4.1%.
  • Adults: AMH prevalence 0.9–17%.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Trauma: Exercise-induced (resolves within 24 hours), blunt abdominal or pelvic trauma, iatrogenic (catheters, surgery).
  • Neoplasms: Urologic malignancies, benign tumors, endometriosis of urinary tract (cyclic hematuria in females).
  • Infectious/inflammatory: UTI (most common in adults), radiation nephritis, tubulointerstitial nephritis, glomerulonephritis (GN) such as IgA nephropathy, Goodpasture syndrome, lupus nephritis, Henoch-Schönlein purpura.
  • Metabolic: Stones (85% have hematuria), hypercalciuria, hyperuricosuria, drug-induced calculi.
  • Congenital/familial: Polycystic kidney disease, thin basement membrane nephropathy, Alport syndrome, Fabry disease, nail-patella syndrome, renal tubular acidosis type 1.
  • Hematologic: Bleeding disorders, sickle cell anemia/trait.
  • Vascular: Hemangioma, AV malformations, nutcracker syndrome, renal artery/vein thrombosis.
  • Chemical: Aminoglycosides, cyclophosphamide, anticoagulants, NSAIDs, oral contraceptives.
  • Obstruction: Strictures, posterior urethral valves, hydronephrosis, benign prostatic hyperplasia.

RISK FACTORS

  • Smoking
  • Occupational exposure to dyes, rubber, petrochemicals
  • Medications (e.g., cyclophosphamide, long-term pioglitazone)
  • Pelvic radiation
  • Chronic infections and stones
  • Recent URI
  • Positive family history of stones, GN, or cancer
  • Chronic indwelling catheters

DIAGNOSIS

History

  • Urinary symptoms: burning, frequency, urgency → UTI
  • Dark cola-colored urine → glomerular bleeding
  • Clots → extraglomerular bleeding
  • Systemic symptoms: arthritis, rash (lupus, vasculitis)
  • Flank pain → stones, infarction, pyelonephritis
  • Recent URI → postinfectious GN, IgA nephropathy
  • Excessive vitamin intake → stones
  • Trauma, strenuous exercise, travel (schistosomiasis, TB)
  • Painless hematuria with weight loss → malignancy
  • Family history (Alport, sickle cell, polycystic kidney, IgA nephropathy)

Physical Exam

  • Elevated BP, edema, weight gain → glomerular disease
  • Fever → infection
  • Palpable kidney mass → neoplasm, polycystic disease
  • Genital examination for lesions

Differential Diagnosis

  • Menstrual/vaginal or rectal bleeding
  • Urine discoloration from medications (rifampin, phenazopyridine)

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests

  • Urine dipstick: high sensitivity (91–100%) but variable specificity (65–99%)
  • Microscopic urinalysis to confirm and quantify RBCs
  • AUA defines significant AMH as ≥3 RBCs/HPF on properly collected sample without benign cause
  • False positives: oxidizers, alkaline urine, semen contamination, hemolysis, rhabdomyolysis
  • RBC casts and dysmorphic RBCs indicate glomerular source
  • Renal function tests (BUN, creatinine, electrolytes), albumin
  • Urine culture if infection suspected

Imaging

  • Multidetector CT urography (MDCTU): 95% sensitivity, 92% specificity for urinary tract lesions; preferred initial imaging in adults without contraindications.
  • Renal/bladder ultrasound (RBUS): good for cystic vs. solid masses, hydronephrosis; first line in pregnancy and low-risk patients.
  • MRI urography: alternative if CT contraindicated; better for parenchymal lesions.
  • Noncontrast CT for stones; contrast-enhanced for trauma or malignancy suspicion.
  • Voided urine cytology: limited sensitivity, useful in high-risk patients.
  • Flexible cystoscopy: gold standard for bladder evaluation in high-risk or patients >35 years.

Other Tests

  • Renal biopsy for glomerulonephritis or unexplained renal impairment.
  • Retrograde pyelogram or ureteroscopy for further evaluation if needed.
  • Labs for systemic disease: ANCA, complement levels, ASO titer, hemoglobin electrophoresis.

Pediatric and Pregnancy Considerations

  • Pediatric: UTI, GN, Wilms tumor, abuse, hypercalciuria, familial causes; repeat dipstick before workup.
  • Pregnancy: Ultrasound initial imaging; MRI or retrograde pyelogram if needed.

TREATMENT

Medications

  • Treat underlying cause.
  • Discontinue causative drugs.
  • UTI: antibiotics.
  • GN: immunosuppressants if indicated.
  • Stones: hydration, pain control, lithotripsy if needed.
  • Endometriosis: surgical removal if symptomatic.

Referral

  • Nephrology: proteinuria, red cell casts, elevated creatinine, albuminuria.
  • Urology: stones, tumors, vascular anomalies.

Surgery

  • As indicated for tumors, obstruction, endometriosis.

ONGOING CARE

  • Specialist follow-up based on etiology.
  • Repeat urinalysis after 12 months if initial negative; annual urinalysis until two negatives recommended by AUA.
  • Monitor for symptom recurrence.

Prognosis

  • Excellent for benign causes.
  • Worse with malignancies and severe nephritis.
  • Persistent AMH in young adults linked with increased risk of end-stage renal disease.

Clinical Pearls

  • USPSTF recommends against routine screening for asymptomatic microscopic hematuria.
  • Any episode of visible hematuria significantly increases odds for urologic cancer.
  • Anticoagulation does not exclude need for hematuria workup.
  • Persistent hematuria mandates nephrologic and urologic evaluation.

References

  1. Linder BJ, Bass EJ, Mostafid H, et al. Guideline of guidelines: asymptomatic microscopic haematuria. BJU Int. 2018;121(2):176-183.
  2. Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU guideline. J Urol. 2020;204(4):778-786.