Transcript Evaluation of Microscopic Hematuria

Evaluation of Microscopic
Hematuria
Gil C. Grimes, MD
December 17 2002
Case
HPI 48 yo male
Right sided back pain for 3 weeks
 Some radiation to groin
 Recent increase in physical activity
 Tilling a field in an old tractor
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Case
PMH
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Seasonal allergies
Depression in remission
PSH
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Tonsillectomy
Social
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Tobacco one pack per day for 18 years
Alcohol rare
Drugs negative
Case
Meds
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No Rx
No OTC
No herbals or vitamins
Fam Hx
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CAD, Fibromyalgia
ROS
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No N/V/F/NS/Wt loss/Dysuria/Hematuria/ED
Case
Physical
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118/66 T-97.9 P 84 Wt 202
Gen- NAD WDWN
CV- RRR w/o M/C/T, no Bruits
Chest- CTAP
ABD- NTND + BS, No HSM
BACK- no CVA tenderness, mild paraspinous
tenderness at L5
GU- normal circ male no hernia
Case
Labs
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UA 1.025, pH 6.0
Trace ketone
Bili positive
Blood 2+
RBC 13-19
WBC 0-1
LE Neg
Nitrite Neg
Culture Negative
What is Microscopic
hematuria?
2-3 RBC per HPF or >5 RBC
Guideline settled on 3 RBC per HPF on 2 of 3
specimens
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Hedge low risk patients
Freshly voided clean catch midstream
specimen (1)
Dipstick
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Sensitivity 91-100%
Specificity 65-99% (2,3)
Confirm all dipstick results with micropscopy
Microscopy
Chamber count
Resuspension of sediment
This is easier
 Semiquantitative
 Centrifuge 10 cc urine 5 minutes 2000
RPM
 Discard supernatent
 Resuspend in 0.5-1.0 mL of urine
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Risk factors (1)
Smoking history
Occupational exposure to chemicals or dyes
(benzenes or aromatic amines)
History of gross hematuria
Age >40 years
History of urologic disorder or disease
History of irritative voiding symptoms
History of urinary tract infection
Analgesic abuse
History of pelvic irradiation
Prevalence
9-18% individuals with hematuria
Young Men 18-33 tested yearly for 15
years (4)
1000 patients
 38.7% had one episode
 16.1% had two episodes (in any 5 year
period)
 One case of transitional cell cancer
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Causes
Life threatening (1)
Bladder, Renal cell, Prostate cancer
 Ureteral or Renal transitional cell
carcinoma
 Metastatic cancer
 Uretheral and penile cancer
 Renal lymphoma
 Abdominal aortic aneruysm
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Causes
Significant requiring treatment
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Renal, Ureteral, or Bladder calculus
Vesicoureteral reflux
Bacterial cystitis
Ureteropelvic junction obstruction
Renal parenchymal disease
Symptomatic BPH
Uretheral stricture or meatal stensosis
Bladder papilloma
Mycobacterial cystitis
Renal artery stenosis
Renal vein thrombosis
Causes
Significant requiring observation
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Radiation cystitis
Bladder diverticulum
Atrophic kidney
Bladder neck contracture and phimosis
Interstitial or eosinophilic cystitis
Asymptomatic BPH and prostatitis
Papillary necrosis
Renal ateriovenous fistula
Renal contusion
Polycystic kidney disease
Cystocoele, Ureterocele
Neurogenic Bladder
Insignificant
Uretherotrigonitis
Renal cyst
Duplicated collecting
system
Prostatic calculus
Bladder neck and
Uretheral polyps
Bladder varices or
telangictasia
Uretheral caruncle
Pseudomembranous
trigonitis
Uretheritis
Pelvic kidney
Caliceal Diverticulum
Exercise Hematuria
Scarred kidney
Trabeculated bladder
Evaluation
Evaluation
Evaluation
Imaging
Intravenous urography
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Considered by many to be best initial study for
evaluation of urinary tract
Widely available and most cost-efficient in most
centers
Limited sensitivity in detecting small renal masses
Cannot distinguish solid from cystic masses
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further lesion characterization by ultrasonography,
computed tomography or magnetic resonance imaging is
necessary
Better than ultrasonography for detection of
transitional cell carcinoma in kidney or ureter
Imaging
Ultrasonography
Excellent for detection and characterization
of renal cysts
 Limitations in detection of small solid
lesions (<3 cm)
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Imaging
Computed tomography
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Preferred modality for detection and
characterization of solid renal masses
Detection rate for renal masses comparable to
that of magnetic resonance imaging, but more
widely available and less expensive
Best modality for evaluation of urinary stones,
renal and perirenal infections, and associated
complications
Sensitivity of 94% to 98% for detection of renal
stones, compared with 52% to 59% for
intravenous urography and 19% for
ultrasonography
Followup
Referances
1.
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5.
Grossfield GD, Litwin MS, Wolf JS, Hricak H, Shuller CL,
Agerter DC, Carroll PR Evaluation of asymptomatic
microscopic hematuria in adults: the American Urological
Association best practice policy-part I: Definition,detection,
prevelence, and etiology Urology 57: 599-603, 2001
Sutton JM, Evaluation of Hematuria in adults JAMA
263:2475-2480, 1990
Corin HL, and Silverstein MD, Micropscopic hematuria Clin
Lab Med 8:601-910, 1988
Froom P, Ribak J, Benbassat J. Significance of microhemturia
in young adults BMJ 288:20-22, 1984
Grossfield GD, Litwin MS, Wolf JS, Hricak H, Shuller CL,
Agerter DC, Carroll PR Evaluation of asymptomatic
microscopic hematuria in adults: the American Urological
Association best practice policy-part Ii: Patient evaluation,
cytology, voided markers, imaging, cystoscopy, nephrology
evaluation, and follow-up, Urology 57: 604-610, 2001