I. Isolated hematuria (without protein, cells, casts)

  1. Usually due to bleeding in urinary tract
  2. If blood is present evenly throughout voiding ("total hematuria") suggests source is bladder or above, because blood has had opportunity to mix with urine; otherwise, probably of urethral or prostatic origin
  3. Causes
  1. Calculi
  2. Neoplasm
  3. TB
  4. Trauma
  5. Prostatitis
  6. Primary renal causes (rare): focal glomerulonephritis (usually has RBC casts), analgesic nephropathy, sickle cell anemia (usually sl. proteinuria, papillary necrosis, and azotemia), thin glomerular basement membrane disease
  1. Approach:
  1. Px of prostate and external urethra
  2. Platelets/coags
  3. Urine cx
  4. IVP and renal u/s
  5. If no lesion seen, cystoscopy and maybe retrograde pyelography
  1. If blood from only one ureter, suggests local process rather than primary renal disease
  1. Further imaging: CT kidney, renal arteriography
  2. Urine cytology

II. Hematuria with UTI-a frequent occurrence; should at least repeat u/a after tx to make sure it's resolved

III. Hematuria with evidence of renal disease

  1. RBC casts are formed by combination of tubular blood & tubular mucoprotein
  2. Caused by primary renal disease, e.g. glomerulonephritis, tubulointerstitial disease, nephronal vasculitis
  3. Often accompanied by proteinuria (glomerular or tubular)
  4. Still need w/u for sources of urinary tract bleeding
  5. Crenated red cells traditionally thought to indicate glomerular source, but are highly nonspecific
  6. Acanthocytes (donut-shaped RBCs with central hole) are specific for upper-tract source