Asymptomatic ( isolated ) hematuria broadly does not require discussion. In conditions associated with abnormal clinical, testing ground, or imaging studies, treatment may be necessary, as appropriate, with the chief diagnosis .
Microscopy of urinary sediment. typical appearance in non-glomerular hematuria : red blood cell are uniform in size and shape but show two populations of cells because a small number have lost their hemoglobin pigment.
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Signs and symptoms
The first base footprint in the evaluation of hematuria consists of a detail history and a exhaustive physical examination. Efforts should be made to distinguish glomerular causes from extraglomerular ones, as follows :
- passage of clots in urine suggests an extraglomerular induce .
- Fever, abdominal pain, dysuria, frequency, and holocene enuresis in older children may point to a urinary tract infection as the causal agent .
- holocene trauma to the abdomen may be indicative mood of hydronephrosis .
- Early-morning periorbital swelling, weight gain, oliguria, dark-colored urine, and edema or high blood pressure suggest a glomerular cause .
- Hematuria due to glomerular causes is painless .
- recent throat or skin infection may suggest postinfectious glomerulonephritis .
- articulation pains, hide rashes, and prolonged fever in adolescents suggest a collagen vascular perturb .
- Anemia can not be accounted for by hematuria alone ; in a affected role with hematuria and lividness, other conditions should be considered .
- Skin rashes and arthritis can occur in Henoch-Schönlein purpura and systemic lupus erythematosus .
- information regarding use, menstruation, late bladder catheterization, intake of certain drugs or toxic substances, or passage of a calculus may besides assist in the derived function diagnosis .
- A family history that is suggestive of Alport syndrome, collagen vascular diseases, urolithiasis, or polycystic kidney disease is authoritative .
physical examination should include the play along :
- measurement of the blood pressure ( with an appropriately sized cuff )
- evaluation for the presence of periorbital ostentation or peripheral edema
- Detailed clamber examination to look for purpura and/or petechia
- abdominal examination to look for palpable kidneys
- careful examination of the genitalia
- Detailed ophthalmologic evaluation ( in familial hematuria )
The follow findings help distinguish between glomerular and nonglomerular hematuria :
- glomerular hematuria : Brown-colored urine, RBC casts, and dysmorphic ( small, deformed, misshapen, sometimes fragmented ) RBCs and albuminuria
- Nonglomerular hematuria : red or pink urine, passage of blood clots, and eumorphic ( normal-sized, biconcavely shaped ) erythrocytes
See clinical Presentation for more detail .
The lab tests ordered for the evaluation of hematuria must be based on the clinical history and the forcible examination. Tests that may be helpful include the surveil :
- urinalysis with careful microscopic review of the urine sample .
- Phase-contrast microscopy to help determine the generator of the shed blood. In clinical practice this test is not always feasible .
- Electrolyte, lineage urea nitrogen ( BUN ), and serum creatinine levels .
- Hematologic and curdling studies ( eg, arrant blood count [ CBC ] and, sometimes, platelet counts ) .
- Random urine calcium and creatinine levels .
- serologic examination ( eg, complement, antistreptolysin [ ASO ], anti-DNase B, antinuclear antibody [ ANA ], and double-stranded DNA [ dsDNA ], ANCA ) .
- urine culture for suspected urinary tract infection ( UTI ) .
The following imagination studies may be helpful :
- Renal and bladder sonography
- Spiral computed imaging ( CT )
- Voiding cystourethrography
- Radionuclide studies
intravenous urography rarely contributes extra information in the evaluation of hematuria and results in unnecessary vulnerability to ionizing radiation .
A kidney biopsy is rarely indicated in the evaluation of isolated asymptomatic hematuria. proportional indications for performing a kidney biopsy in patients with hematuria are as follows :
- significant albuminuria
- Abnormal nephritic function
- perennial persistent hematuria
- serologic abnormalities ( abnormal complement, ANA, or dsDNA levels )
- Recurrent arrant hematuria
- A family history of end-stage nephritic disease
In most patients, a nephritic biopsy either is normal or reveals minor changes, such as sparse glomerular basement membranes, focal glomerulonephritis, or mild mesangial hypercellularity. In a minority of patients, histological findings, together with historic or serologic data, may point to specific conditions .
Hematuria may be categorized as follows :
- Gross hematuria
- Microscopic hematuria with clinical symptoms
- asymptomatic microscopic hematuria with proteinuria
- asymptomatic microscopic ( isolated ) hematuria
See Workup for more contingent .
General principles of treatment are as follows :
- Hematuria is a signboard and not itself a disease ; therefore, therapy should be directed at the cause .
- Asymptomatic ( isolated ) hematuria broadly does not require treatment .
- In conditions associated with abnormal clinical, lab, or imaging studies, treatment may be necessity, as allow, with the primary diagnosis .
- surgical intervention may be necessary with certain anatomic abnormalities ( eg, ureteropelvic junction obstacle, tumor, or significant urolithiasis ) but not necessarily to treat hematuria .
- Unlike in adults, cystoscopy does not contribute to the diagnosis in the majority of children .
- dietary modification is normally not indicated .
- Patients with dogged microscopic hematuria should be monitored every 6-12 months for the appearance of signs or symptoms indicative of progressive nephritic disease .
See Treatment and Medication for more contingent .
Guidelines on hematuria from the American College of Physicians ( ACP ) advise that clinicians should include gross hematuria in their everyday review of systems and specifically ask all patients with microscopic hematuria about any history of gross hematuria. [ 2 ]
The ACP besides makes the follow recommendations [ 2 ] :
Clinicians should confirm heme-positive results of dipstick testing with microscopic urinalysis that demonstrates 3 or more erythrocytes per high-powered field before initiating promote evaluation in all asymptomatic patients.
Read more: Gastritis – Symptoms and causes
- Clinicians should pursue evaluation of hematuria even if the patient is receiving antiplatelet or anticoagulant therapy .
- Clinicians should not obtain urinary cytology or other urine-based molecular markers for bladder cancer detection in the initial evaluation of hematuria .