- RBC in urine


By visibility

- Macroscopic/Gross hematuria

- Microscopic hematuria


- identify causes

- associated symptoms

- Timing and intermittent

- clot and shape

- risk factors

- urologic history

- general medical history

- current medication use

- family history

- tobacco-related illness

Identify causes

- infection

- menstruation

- recent vigorous exercise

- Known medical renal disease

- acute viral illness

- trauma

- presence of FB in urinary tract

- recent urologic instrumentation


Associated symptoms

- bleeding symptoms

- gross hematuria

- voiding symptoms

- Flank pain


Timing and intermittent

- initial hematuria: urethra

- terminal hematuria: Bladder trigone, bladder neck, prostate

- total hematuria: bladder or above


Risk factors

common risk factors for urinary tract malignancy in patients with microscopic hematuria

- male gender

- age older than 35 yr

- past or current smoking history

- occupational or other exposure to chemicals or dyes (benzenes or aromatic amines, cyclophosphamide)

- analgesic abuse

- History of gross hematuria

- history of urologic disorder or disease

- history of irritative voiding symptoms

- history of pelvic irradiation

- history of chronic urinary tract infection

- exposure to known carcinogenic agents or chemotherapy (alkylating agents)

- history of chronic indwelling FB


Urologic history

- any surgeries

- febrile UTIs


General medical history

- Hypertension

- renal insufficiency

- bleeding disorders

- sickle cell disease

- G6PD deficiency


Current medication uses

- anticoagulants

- antiplatelet


Family history

- nephritis

- polycystic kidneys

- rare familial tumor syndromes of the kidneys (eg. VHL/von Hippel–Lindau) or urothelium

physical examination

- vital signs

- Flank: tenderness

- masses in flank or abdomen or suprapubic area (bladder) or urethra

* CVA tenderness, bimanual palpation

- PR for prostate gland examination: enlargement, nodular, tenderness or fluctuant

- signs of coagulopathy (bruising)

- infection: tenderness, fever

- renal disease: hypertension, edema

- urethral stricture or benign prostatic hyperplasia: urine flow rate and post-void residual measurement

- Bleeding permeatus: urethal injury


- confirm diagnosis

- identify causes

- investigation

Confirm diagnosis: urine dipstick tests -> urinalysis with microscopy

1. distinguished from pigmenturia

* endogenous: bilirubin, myoglobin

* foods: beets, rhubarb, dragon fruit

* drugs: phenazopyridine, rifampin

*simple dehydration

2. distinguished from vaginal bleeding (in women)

* history: menstrual history

* collecting when not having menstrual or gynecologic bleeding

* obtaining a catheterized


microscopic hematuria

-  ≥ 3 RBCs/HPF

- single positive UA is sufficient to prompt evaluation

- specimens collected first void in morning or after vigorous physical or sexual activity maybe falsely positive for hematuria

Differential diagnosis of asymptomatic microscopic hematuria

- neoplasm

- infection or inflammation

- calculus


- medical renal disease

- congenital or acquired anatomic abnormality

- others


overview of management in asymptomatic microhematuria


indication for investigation in microscopic hematuria

- recommend: evaluation in pt with microscopic hematuria in the abscence of an obvious benign cause

- presence of infection -> confirmed with U/C and UA -> repeat after treatment of UTI to document resolution of the hematuria

- confirmed absence of microscopic hematuria after a period of abstinence from exercise

- pt taking anticoagulant or antiplatelet -> undergoing complete evaluation in same manner


Gross hematuria evaluation

- absence of antecedent trauma or culture-docamented UTI: evaluate with urine cytologic examination, cystoscopy, and upper tract imaging. preferly CT urography

- vital signs (hemodynamic stability?)

- anemia


Common causes of Gross hematuria

* Hemorrhagic cystitis

- infectious

- trauma

- malignancy

- bladder primary

- vascular malformation

- chemical exposure

- radiation therapy history: about 6 months

- medication induced: penicillin, bleomycin (CMT)

- systemic disease


- CBC + platelet count

- coagulogram

- urinalysis: dysmorphic RBC, cellular casts, or proteinuria

- urine culture (if suggest infection)

- renal function testing (serum creatinine)

- prostate-specific antigen

- imaging (eg. cystoscopy, CT urography)

* cystoscopy: most reliable way for presence bladder cancer, can see urethra, prostate gland, seen stone

indication: age older than 35 yr +/- risk factors for malignancy, recommend in symptomatic microhematuria, regardless of age

Specific management

Hemorrhagic cystitis

initial management

- Hydration

- CBI (continuous bladder irrigation): with NSS

- supportive care: pain control

- correctable factor: infection, coagulopathy, tumor


Urethral bleeding evaluation

- women: pelvic examination for clarifying site of origin

- men: most common cause is trauma

- diagnosis by retrograde urethrogram, cystourethroscopy

- other causes: FB insertion, urethritis, urethral tumors (rare)


Upper urinary tract

- medical renal disease

- glomerular diseases: RBC casts, dysmorphic RBCs, proteinuria

- Tubulointerstitial diseases: sickle cell nephropathy

- analgesic nephropathy


Vascular conditions

- ureteroiliac artery fistula : pelvic or vascular surgery, pelvic irradiation, extensive urethral mobilization, and chronic urethral stenting

- renal arteriovenous malformation: renal biopsy, renal surgery, trauma

- renal artery aneurysms and pseudoaneurysms

- Nutcracker syndromes (renal vein entrapment syndrome)

* manangement: angiography and endovascular management