Hematuria is defined as the presence of red blood cells in the urine; normal urine does not contain any blood cells. It can be characterized as either gross/frank (visible to the naked eye) or microscopic (visible only under the microscope). Microscopic hematuria is an incidental finding often discovered on urine tests as part of a routine medical evaluation, whereas gross hematuria could prompt you to visit the doctor. Hematuria can originate from any site along the urinary tract, including the kidneys, ureters, bladder, prostate and urethra. Hematuria may be an indication for infection, stone disease or urinary tract cancer. Risk factors for significant underlying disease include: smoking, radiation, overuse of some pain medicines and exposure to certain chemicals.
Hematuria Signs & Symptoms
Visible hematuria is often worrisome to the patient and prompts them to seek medical attention; however, microscopic hematuria can be just as severe. It often has no symptoms and is detected on a urine dipstick test performed in your physicians’ office. If the dipstick test is positive for blood the amount of blood is often determined through microscopic evaluation.
Any patient with gross hematuria or significant microscopic hematuria should have further evaluation of the urinary tract. The first step is a careful history and physical examination. Laboratory analysis consists of a urinalysis and examination of urinary sediment under a microscope. The urine should be evaluated for protein (a sign of kidney disease) and evidence of urinary tract infection . The number of red blood cells per high-powered field should be determined. In addition, the shape of the blood cells should be evaluated. This can help determine the origin of the bleeding. In patients with white blood cells in the urine, a urine culture should be performed as well. A urinary cytology is also obtained to look for abnormal cells in the urine. Additionally a blood test should be done to measure serum creatinine (a measure of kidney function). Those patients with significant protein in their urine, abnormally shaped red blood cells, or an elevated creatinine level should undergo general medical evaluation for the presence of kidney disease.
Cystoscopy is normally the first test performed to allow a direct view of the inside of the urethra and bladder performed by your urologist. This is usually performed in the office under local anesthesia with a flexible cystoscope. After applying a topical analgesic to the urethra the urologist inserts a fiber-optic camera called a cystoscope through the urethra and into the bladder. Looking through the cystoscope the doctor can examine the inner lining of the bladder and urethra for abnormalities and collect urine samples from the bladder if needed.
A complete urologic evaluation for hematuria also includes X-rays of the kidneys and ureters to detect kidney masses, tumors of the ureters and the presence of urinary stones. This traditionally consisted of an intravenous pyelogram (IVP). In this study, a radiographic dye is injected into the blood stream and X-rays are taken as the kidneys excrete the dye. This study has trouble detecting small renal masses and is often combined with a renal ultrasound.
Many physicians may opt for other imaging studies such as a computerized tomography (CT) scan. This is the preferred method of evaluating kidney masses and is the best modality for the evaluation of urinary stones. Recently many urologists have been using CT urography. This allows the urologist to look at the kidneys and ureters with one X-ray test. In patients with an elevated creatinine or an allergy to X-ray dye, magnetic resonance imaging (MRI) or retrograde pyelography is used to evaluate the upper urinary tract. During retrograde pyelography, the patient is taken to the operating room and dye is injected up the ureters from the bladder and then images are taken.
Treatment will be based on a physician’s evaluation of the patient’s condition, symptoms and medical history along with the cause of the hematuria.