Hematuria

Hematuria is the presence of blood in the urine; greater than

three red blood cells per high-power microscopic field

(HPF) is significant.

Patients with gross hematuria are usually frightened by the sudden onset of blood in the urine and frequently present to the emergency department for evaluation, fearing that they may be bleeding excessively.

Hematuria of any degree should never be ignored and, in adults, should be regarded as a symptom of urologic malignancy until proved otherwise.

In evaluating hematuria, several questions should always be asked, and the answers will enable the urologist to target the subsequent diagnostic evaluation efficiently:

Is the hematuria gross or microscopic?

At what time during urination does the hematuria occur (begin-ning or end of stream or during entire stream)?

Is the hematuria associated with pain?

Is the patient passing clots?

If the patient is passing clots, do the clots have a specific shape?

Gross versus Microscopic Hematuria. The significance of gross versus microscopic hematuria is simply that the chances of identifying significant pathology increase with the degree of hematuria.

Thus patients with gross hematuria usually have identifiable underlying pathology, whereas it is quite common for patients with minimal degrees of microscopic hematuria to Have a Negative urologic evaluation.

Timing of Hematuria. The timing of hematuria during urination frequently indicates the site of origin.

Initial hematuria usually arises from the urethra; it occurs least commonly and is usually secondary to inflammation.

Total hematuria is most common and indicates that the bleeding is most likely coming from the bladder or upper urinary tracts.

Terminal hematuria occurs at the end of micturition and is usually secondary to inflammation in the area of the bladder neck or prostatic urethra. It occurs at the end of micturition as the bladder neck contracts, squeezing out the last amount of urine.

Association with Pain. Hematuria, although frightening, is usually not painful unless it is associated with inflammation or obstruction.

Thus patients with cystitis and secondary hematuria may experience painful urinary irritative symptoms, but the pain is usually not worsened with passage of clots.

More commonly,pain in association with hematuria usually results from upper urinary tract hematuria with obstruction of the ureters with clots. Passage of these clots may be associated with severe, colicky flank pain similar to that produced by a ureteral calculus, and this helps identify the source of the hematuria.

Presence of Clots. The presence of clots usually indicates a more significant degree of hematuria, and, accordingly, the probability of identifying significant urologic pathology increases.

Shape of Clots. Usually, if the patient is passing clots, they are amorphous and of bladder or prostatic urethral origin. However, the presence of vermiform (wormlike) clots, particularly if associated with flank pain, identifies the hematuria as coming from the upper urinary tract with formation of vermiform clots within the ureter. It cannot be emphasized strongly enough that hematuria, particularly in the adult, should be regarded as a symptom of malignancy until proved otherwise and demands immediate urologic examination.

In a patient who presents with gross hematuria, cystoscopy should be performed as soon as possible, because frequently the source of bleeding can be readily identified.

Cystoscopy will determine whether the hematuria is coming from the urethra, bladder, or upper urinary tract. In patients with gross hematuria secondary to an upper tract source, it is easy to see the jet of red urine pulsing from the involved ureteral orifice.

Although inflammatory conditions may result in hematuria, all patients with hematuria, except perhaps young women with acute bacterial hemorrhagic cystitis, should undergo urologic evaluation.

Older women and men who present with hematuria and irritative voiding symptoms may have cystitis secondary to infection arising in a necrotic bladder tumor or, more commonly, flat carcinoma in situ of the bladder.

The most common cause of gross hematuria in a patient older than age 50 years is bladder cancer.