Blood in the Urine/Hematuria
  Blood in the urine or hematuria is one of the most common conditions we see at Alliance Urology Specialists. Blood that is visible to the eye is known as gross hematuria, and blood seen only on a urine specimen is known as microscopic hematuria. Both types of hematuria can be a sign of a serious medical condition and require a thorough evaluation of the urinary system including the kidneys, ureters (the tubes that carry urine from the kidneys), bladder, prostate (in men), and urethra (the tube that carries the urine from the bladder).

All episodes of gross hematuria require an evaluation unless an obvious cause such as a urinary tract infection (UTI) has been identified. Microscopic hematuria is considered significant if there are more than three red blood cells/microscopic field (>3 RBC/HPF) on two separate urine analyses. Many urine analyses done in the primary care physician’s office are performed using a dipstick chemical analysis without a microscopic review. This is a very important screening tool, but urines that are positive only by dipstick test should be confirmed by a microscopic analysis as there can be false positive tests with the dipstick alone.

Once significant hematuria is confirmed, appropriate tests to evaluate each of the urinary structures is required.

History and Physical exam: The initial history and physical exam is very important in making an accurate diagnosis. Symptoms such as flank or abdominal pain or burning with urination can help direct further testing. Associated medical conditions like diabetes, renal disease, and chronic gastrointestinal disorders can be associated with potential causes of hematuria. The physical exam may detect abdominal masses or tenderness that can help localize the source of bleeding. A history of smoking raises a concern for a urologic cancer, and a family history of microscopic bleeding may suggest a benign condition in the kidney.

Lab work: In addition to the urine analysis, a urine culture may be performed to confirm the presence of an infection and to determine appropriate antibiotic coverage.  Urine cytology will be sent if there is a suspicion of a urinary cancer. This test looks for abnormal cells that are shed into the urine by cancers of the lining of the urinary tract. Other urine tests that might be performed the NMP22 and FISH test that can also help evaluate for malignancy. A 24 hour urine collection may be needed if there is a concern for kidney disease.  Blood work including a Blood Urea Nitrogen (BUN) and Creatinine may be required to evaluate kidney function. A Complete Blood Count (CBC) can help determine if the bleeding has caused anemia, or if there is an elevated White Blood Cell count that might suggest a more serious infection.   For individuals on blood thinners like Warfarin (Coumadin) Coagulation Studies (PT, PTT, and INR) can determine if the dose is too high making bleeding more likely.  In men, a Prostate Specific Antigen (PSA) may be indicated to evaluate for prostate cancer.

Upper Tract Studies: The kidneys and ureters are considered the upper tracts of the urinary system and will usually need to be imaged to look for kidney stones, cancer and anatomic abnormalities. For many years, the Intravenous Pyelogram (IVP) was the study of choice for evaluating the upper tracts and is still used for certain indications, but Computerized Tomography (CT) has become a more important tool for the evaluation of hematuria. CT scanning provides much greater detail and sensitivity than an IVP and provides a more thorough evaluation. If there is suspicion of kidney stones, the CT is usually done without contrast, but in most cases x-ray dye or contrast is administered to provide a clearer picture of the kidney and associated structure. Renal Ultrasound can also be used to evaluate the kidneys and bladder, and may be indicated following a CT scan to help clarify the nature of a mass lesion on the kidney, but renal ultrasound does not provide an adequate assessment of the ureters.  Renal ultrasound can be an adequate study for individuals at very low risk of abnormal findings, or in those with poor kidney function who can’t tolerate the dye used with CT or IVP.

Cystoscopy: Cystoscopy is an endoscopic test that allows a urologist to look at the lower urinary tract for sources of bleeding. This test is usually done in the urologist’s office using a small flexible endoscope to examine the urethra, the prostate (in men), and the bladder wall. While CT scanning is a very good test, it is not always able to identify a bladder wall or prostate lesion. Cystoscopy can also help determine which kidney blood is coming from if done while the bleeding is active. If a small bladder lesion is identified, it is sometimes possible to biopsy and cauterize the lesion in the office, but if the lesion is larger or there is problem noted in the kidney or ureter that needs further evaluation, cystoscopy may have to be performed or repeated under anesthesia at the hospital or outpatient surgical center. Retrograde Pyelography is a procedure where contrast or x-ray dye is injected up the ureter during cystoscopy to help evaluate an abnormality in the ureter or kidney that was seen on other imaging studies or in individuals with poor kidney function who cannot tolerate intravenous injection of contrast or x-ray dye. Ureteroscopy may also be needed to evaluate the ureter and kidney if there is a suspicion of cancer in the upper tracts. This test involves passage of very small rigid or flexible endoscope up the ureter to the kidney allowing visual inspection of the drainage system with biopsy if necessary.

Blood in the urine can come from a great variety of causes. The most common causes include: Urinary Tract Infection, Kidney Stones, Benign Prostate Hypertrophy (BPH), Kidney, Bladder and Prostate Cancer, Trauma, and Medical Kidney Disease.  A thorough evaluation of clinically significant microscopic and gross hematuria is imperative to detect and treat serious urologic conditions in their earliest stage.

Alliance Urology Specialists is a full service urologic practice with on-site CT scanning, diagnostic X-ray, and Ultrasound. In most cases, we are able to determine the cause of hematuria in as few as one to two office visits without the need for trips to outside labs or imaging centers. We are able to provide a rapid diagnosis to ease your anxiety about your condition, and then provide treatment in a skillful and timely fashion.

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