Gross hematuria requires a thorough diagnostic evaluation.

Microscopic hematuria requires three or more red blood cells per high-powered field on microscopic evaluation of urinary sediment from two of three properly collected urinalysis specimens.

Cystoscopy is the mainstay in the initial work up with visualization of the entire bladder lumen and resection of any mucosal abnormalities.

CT urography of the upper urinary tract is also indicated in evaluation of painless hematuria if cystoscope is negative.

Can be categorized as having a glomerular or non-glomerular cause.

In glomerular hematuria, red cells are dysmorphic, red blood cell casts are present on light microscopy examination of urine, and urine dipstick tests indicate the presence of proteinuria.

Usually a renal biopsy is required to discriminate among the different types of glomerular hematuria.

In non-glomerular hematuria red blood cells are normal in appearance and casts are not present.

Non-glomerular hematuria can be sub categorized into non-urologic and urologic entities.

Non-glomerular, non urologic hematuria is caused by interstitial diseases, often accompanied by protein in the urine.

Renal papillary necrosis or vascular diseases account for many cases of non-glomerular , non-urologic cases of hematuria

Urinary tract infection most common cause, especially in young women.

Patients with asymptomatic microscopic hematuria at risk for urologic disease or primary renal disease should undergo appropriate evaluation.

Persistent asymptomatic isolated microscopic hematuria is a common incidental finding on routine examination of children, adolescents and young adults.

Microhematuria Prevalence among healthy patients ranges from 2.4-31.1%.
Patient with microhematuria attributed to a gynecologic or diagnosed urologic etiology, such as a UTI should have repeat urinalysis after resolution of the causative condition.

Microscopic examination is the gold standard for detecting microscopic hematuria.

Microscopic hematuria can be an isolated finding, an accompaniment by other kidney or urologic abnormalities or part of a systemic process that can be transient or persistent.

Asymptomatic microscopic hematuria associated with malignancy in only 0.5-5% of patients (Schwartz GL).

Prevalence of asymptomatic microscopic hematuria varies from 0.19 percent to as high as 21%.

Microhematuria should be categorized as low, intermediate, or high risk genitourinary malignancy based on risk factors.

The prevalence of microhematuria varies greatly from a small percentage of patients at screening, to more than 40% in urologic clinics, the latter owing to referral bias.



Prevalence of microscopic hematuria ranges from 2.1–31.4% and there is considerably variation with geography: northern Africa where  Schistosoma hematobium is endemic, microscopic hematuria is common, reflecting bladder infestation.



Cancer is more likely to be present in men than in women when being evaluated for microscopic hematuria.

Low risk patients should have a repeat urinalysis within six months or a cystoscopy and kidney ultrasound.
Intermediate risk patients should undergo cystoscopy and kidney ultrasound.
High risk patients should undergo cystoscopy and axial upper tract imaging, preferably multiphasic CT urography.

Prevalence of some degree of hematuria reported to be as high as 9-18% in large screening studies.

Prevalence of urinary tract cancers is reported to be 5-13% among patients being evaluated for microscopic hematuria.

In a retrospective analysis of patients who underwent microscopic urinalysis during a two year period the prevalence of urinary tract cancer was 0.43% (Jung H et al).

In patients with gross hematuria in the setting of antiplatelet or anticoagulation therapy a new diagnosis of urinary tract malignancy was noted in 24% of cases.

This finding occurs in the setting of antiplatelet or anticoagulation therapy at the same rate.

Microscopic hematuria is unreliable indicator of the presence of the urothelial or renal malignant lesion, with only a very small proportion of patients with microscopic hematuria subsequently found to have a cancer.

Women are at risk of delay diagnosis of bladder cancer due to miss attribution of microhematuria to equivocal urinary tract infections or a gynecological cause without repeat urinalysis to confirm resolution of the microhematuria.
90% of patients with bladder cancer present with hematuria.

The persistence of asymptomatic isolated microscopic hematuria in persons aged 15-25 years was associated with a significant increased risk of end-stage real disease (Vivante A et al).

Evaluation often fails to find a cause and is generally considered benign hematuria, or if familial, benign familial hematuria.

Renal biopsy is usually not considered helpful in patients with isolated microscopic hematuria.

Majority of patients have no symptoms.

4% of asymptomatic microscopic hematuria and valuations yield a diagnosis of malignancy.

13.1% of gross hematuria episodes are associated with malignancy.

Other diagnoses made during the work up of the patient with asymptomatic microscopic hematuria includes nephrolithiasis and BPH.

The frequency of serious urological disease in patients with asymptomatic microscopic hematuria is lowv with malignancies ranging from 0.5-5%.

Pain accompanying hematuria is common and may be a direct result of the hematuria.

Associated pain may provide clue to the diagnosis: sharp flank or lower abdominal pain suggests the ureter is obstructed.

Pain associated may be due to a ureteral stone.

Pain may be related to bleeding in the upper urinary tract and can cause pain as the clot traverses the ureter.

Pain may be associated with urination and be indicative of bladder infection.

The presence of hematuria with pain, more often flank or groin pain, usually means kidney stones and initially will proceed down there diagnostic and therapeutic pathway.

Gross hematuria in the absence of pain is associated with more ominous underlying causes with the probability between 10-25% for serious genitourinary tract disease and an odds ratio for urologic cancer of 7.2, including cancer of the bladder or kidney.

Gross hematuria is presenting symptoms in 75-90% of patients with tumors of the renal pelvis and ureters.

Macroscopic hematuria caused by cancer in 17-27% of cases, most being transitional cell cancer of the bladder.

1-5% of individuals with hematuria have bladder cancer.

Gross hematuria is a far more reliable indicator of the presence of a malignancy and the need for urologic evaluation and imaging than is microscopic hematuria.

Normally approximately 1.2 million RBC’s are lost in the urine each day, accounting for the 1-2 RBC’s per high-powered field of centrifuged fresh urine.

More than 3 RBC’s per high-powered field in a urinalysis is abnormal and should be investigated.

Benign orthostatic hematuria common cause of hematuria in adolescents and young adults.

Episodic events can occur in distance runners and athletes who play a contact sport.

Threshold for evaluation of hematuria is three or more red blood cells per high-powered field on two of three urine analyses or any high-grade hematuria with greater than 50 red blood cells per high-powered field or gross hematuria.

American Urologic Association recommends for evaluation of hematuria: urine testing with the urine culture or urine cytology, imaging with CT or IVP plus real ultrasound and cystoscopy.

In the absence of over anticoagulation patients on anticoagulants with any abnormal bleeding is not to be expected and should be evaluated in the usual manner with demonstration of pathology in as as many as 80% of cases.

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