Hematuria

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Overview
Hematuria (or "haematuria") is the presence of red blood cells (erythrocytes) in the urine. Occasionally the term "hemoglobinuria" is used synonymously, although more precisely it refers only to hemoglobin in the urine.

Types of Hematuria
Red discoloration of the urine can have various causes:
 * Red blood cells
 * Microscopic hematuria (small amounts of blood, can be seen only on urinalysis or light microscopy)
 * Macroscopic hematuria (or "frank" or "gross") hematuria
 * Hemoglobin (only the red pigment, not the red blood cells)
 * Other pigments
 * Porphyrins in porphyria
 * Betanin, after eating beets

Symptoms
In assessing the underlying cause of hematuria, the patient should be asked the following questions::
 * Have you passed any blood clots?
 * Has a kidney stone been passed (have you heard a noise in toilet bowl)?
 * Is the red color mixed in completely, or does the color change during an episode of urination?
 * Does it occur only after getting up?
 * Have you recently had a sore throat?

Diagnosis
Often, the diagnosis is made on the basis of the medical history and some blood tests&mdash;especially in young people in whom the risk of malignancy is negligible and the symptoms are generally self-limited.

Ultrasound investigation of the renal tract is often used to distinguish between various sources of bleeding. X-rays can be used to identify kidney stones, although CT scanning is more precise.

In older patients, cystoscopy with biopsy of suspected lesions is often employed to investigate for bladder cancer.


 * Urinalysis for all patients
 * Complete blood count (CBC)
 * Calcium
 * Uric acid
 * Prothrombin time / Partial thromboplastin time (PT / PTT)
 * Blood urea nitrogen (BUN) / creatinine

A more complete evaluation would include the following:
 * C3 levels
 * Red blood cells casts
 * Cyroglobulins
 * Hepatitis C antibodies
 * Anti-glomerular basement membranes (GBM)
 * Antinuclear anitbodies (ANA)
 * Antineutrophil cytoplasmic antibodies (ANCA)
 * Antistreptolysin O antibodies (ASO)

Common Causes
Common causes of macroscopic hematuria/ haematuria (i.e. blood visible in the urine) include:
 * Benign familial hematuria
 * Urinary Schistosomiasis (caused by Schistosoma haematobium) - a major cause for hematuria in many African and Middle-Eastern countries;
 * IgA nephropathy ("Berger's disease") - occurs during viral infections in predisposed patients;
 * Kidney stones (or bladder stones, now a rare disease);
 * Bladder cancer;
 * Renal cell carcinoma - occasionally presents with bleeding;
 * Paroxysmal nocturnal hemoglobinuria - a rare disease where hemoglobin of hemolysed cells is passed into the urine.
 * Urinary tract infection with some bacterial species including strains of EPEC and Staphylococcus saprophyticus
 * Sickle cell trait can precipitate large amounts of red blood cell discharge, but only a small number of individuals endure this problem
 * Arteriovenous malformation of the kidney (rare, but may impress like renal cell carcinoma on scans as both are highly vascular)
 * Nephritic syndrome ( a condition associated with post-streptococcal and rapidly progressing glomerulonephritis.
 * Ureteral Pelvic Junction Obstruction (UPJ) is a rare condition beginning from birth in which the ureter is blocked between the kidney and bladder. This condition may cause blood in the urine.

Differential Diagnosis
In alphabetical order.

Main Causes

 * Bladder carcinoma
 * Contamination during menstruation
 * Cystitis
 * Glomerulonephritis
 * Prostatic hypertrophy
 * Pyelonephritis
 * Prostatitis
 * Renal carcinoma
 * Stones
 * Urinary Tract Infection (UTI)

Other Causes

 * Acute/chronic Cystitis
 * Acute intestinal nephritis
 * Adenovirus
 * After Endocarditis
 * Allergic Granulomatosis
 * Alport's Syndrome
 * Analgesic kidney
 * Arteriosclerosis
 * Balkan Nephropathy
 * Beeturia
 * Benign familial hematuria
 * Berger's Disease
 * Bilharziosis
 * Bladder infiltration
 * Bladder tuberculosis
 * Calyx Diverticulum
 * Chemotherapeutics
 * Consumption coagulopathy
 * Crescentic glomerulonephritis
 * Cystic kidneys
 * Cytomegalovirus (CMV)
 * Dermatosclerosis
 * Diabetes Mellitus
 * Diabetic glomerulosclerosis/diabetic nephropathy
 * Drugs
 * ECHO viruses (Enteric Cytopathic Human Orphan)
 * E.coli
 * Endometriosis
 * Fabry's Disease
 * Factor lack
 * Filaria
 * Fistula
 * Focal glomerulotnephritis
 * Foods
 * Foreign body in urethra
 * Goodpasture's Syndrome
 * Heart failure
 * Heavy exercise
 * Hemoglobinopathy
 * Hemophilia
 * Hemolytic Uremic Syndrome
 * Hemorrhage from bladder outlet
 * Hemorrhage from urethra
 * Hepatitis B
 * Hydronephrosis
 * Hypernephroma
 * Hypertension
 * Inflammation
 * Influenza
 * Injury
 * Kidney Amyloidosis
 * Kidney cell carcinoma
 * Kidney tuberculosis
 * Legionella Infection
 * Systemic Lupus Erythematosus
 * Malignant Hypertension
 * Masturbation
 * Meatus Stenosis
 * Megaureter
 * Membranoproliferative glomerulonephritis
 * Metastases
 * Mononucleosis
 * Multiple Myeloma
 * Mycoplasma
 * Myoglobinuria
 * Nail-Patella Syndrome
 * Neoplasm
 * Nephrocalcinosis
 * Nephrolithiasis
 * Osler's Disease
 * Polyarteritis Nodosa
 * Polycystic Kidney Disease
 * Polycythemia Vera
 * Porphyria
 * Postinfectious glomerulonephritis
 * Plasmodium
 * Prostate adenoma
 * Prostate carcinoma
 * Prostate hyperplasia
 * Prostate tuberculosis
 * Pseudomonas
 * Pyelonephritis
 * Radiation nephropathy
 * Renal artery aneurysm
 * Renal cyst
 * Renal hyperplasia
 * Renal infarct
 * Renal pelvis carcinoma
 * Renal Stones
 * Renal trauma
 * Renal vein infarct
 * Renal Vein Thrombosis
 * Salmonella
 * Sarcoidosis
 * Schistosoma
 * Schonlein-Henoch's Disease
 * Shock
 * Shunt nephritis
 * Sickle Cell Anemia
 * Sponge kidney
 * Staphylococci
 * Streptococci
 * Thalassemia
 * Thin Basement Membrane Disease
 * Thrombocytopathies
 * Thrombocytopenia
 * Thrombotic Thrombocytopenic Purpura
 * Toxins
 * Toxoplasma
 * Trauma
 * Traumatic kidney lesion
 * Trichinella Spiralis
 * Tubulointerstitial nephropathies, nephritis
 * Tumor
 * Urate nephropathy
 * Ureter carcinoma
 * Ureter tuberculosis
 * Urethra carcinoma
 * Urethral carbuncle
 * Urethral valves
 * Urethritis
 * Urethrolithiasis
 * Urogential tuberculosis
 * Urolithiasis
 * Urothelium carcinoma
 * Varicella
 * Vesical calculi
 * Vesico-ureteral-renal reflux
 * Warfarin therapy (overdose)
 * Wegener's Granulomatosis
 * Wilms' Tumor

Other Diagnostic Studies

 * Three-tube test
 * Centrifuge urine sample
 * Urine cytology
 * Urine cytoscopy
 * Renal biopsy

= Treatment =
 * Older patients with transient hematuria should be evaluated for urinary tract cancers
 * Urologic consult if necessary
 * Treat underlying etiologies
 * Increase hydration (stones)

Acute Pharmacotherapies

 * Antibiotics (UTI)
 * Analgesics (stones)

Surgery and Device Based Therapy

 * Biopsy for patients for glomerular sources

Acknowledgements
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Hematuria