354

Practical Urology: EssEntial PrinciPlEs and PracticE

renal biopsy in order to diagnose the nature of

chemicals or dyes such as benzenes or aromatic

the underlying renal parenchymal disease.

amines, previous pelvic irradiation, and a his-

Patients with microscopic hematuria in the

tory of irritative urinary symptoms.

absence of demonstrable urological or nephro-

It is important to be sure that the bleeding is

logical pathology should be considered at high

definitely from the urinary tract, rather than

risk of developing renal disease (mostly IgA

from a colorectal or gynecological cause, and

nephropathy).These patients should be followed

the patient’s past medical history and drug his-

up in a primary care setting and referred to a

tory are important.

renal physician if they develop hypertension,

renal insufficiency, or significant proteinuria.6

Examination

Assessment

Patients with macroscopic hematuria should

have their vital signs measured to check if they

are hemodynamically stable. Unstable patients

History

may require resuscitation and blood transfu-

sion. Patients should undergo abdominal exam-

History taking should try to establish the causes

ination to exclude a renal or bladder mass. In

men, genital examination and digital rectal

of hematuria22 (Table 26.1), predisposing dis-

ease factors, and establish the risk of underlying

examination to detect the presence of prostatic

pathology are required. Female patients should

pathology. For example, macroscopic hematuria

undergo a pelvic examination to exclude a mass.

has a higher risk of pathology than that detected

All patients presenting to the hematuria clinic

by dipstick, while the absence of associated pain

should have their blood pressure checked to

is a feature of malignancy. The presence of asso-

exclude hypertension (suggestive of renal patho-

ciated symptoms should be established,

for

logy as a possible cause of hematuria).

example, dysuria may indicate an infective or

inflammatory cause while colicky loin pain may

Investigations

indicate an upper tract calculus. Difficulty pass-

ing urine in the presence of frank hematuria,

The ideal practice is probably a “one-stop”

particularly if there are associated clots, sug-

gests that the patient is developing clot retention

hematuria clinic in which synchronous clinical

and will require catheterization with a three-

and radiological evaluation of the patient is per-

way catheter.The timing of hematuria may point

formed. This design reduces diagnostic delay

to the underlying source: initial hematuria sug-

and patient anxiety.

gests urethral pathology, hematuria throughout

the stream suggests an intravesical or upper

Dipstick Urinalysis

tract cause, while terminal bleeding suggests

A fresh uncontaminated mid-stream urine (MSU)

that it is from the bladder neck or prostate. The

presence of associated clots indicates a signifi-

sample should be dipstick tested for blood, pro-

cant amount of hematuria and is associated with

tein (renal disease),nitrate (infection),leukocytes

a greater probability of finding serious underly-

(inflammation), and glucose (diabetes). Urine

ing pathology such as a malignancy.If the hema-

samples should also be sent for microscopy, cul-

turia is microscopic in nature,then it is important

ture, and sensitivity (MC&S). Patients found to

to establish whether this is a recurrent finding,

have nitrites on dipstick urinalysis, but asymp-

as this would indicate a greater chance of find-

tomatic for infection, should receive a prophylac-

ing significant underlying pathology.

tic dose of antibiotic at the time of flexible

The age of the patient is important as patients

cystoscopic evaluation of the lower urinary tract

over the age of 40 years have a greater chance of

(see later) followed by a course of antibiotics in

harboring significant underlying pathology.5

order to minimize the risk of precipitating an

The history should also focus on identifying the

upper tract or systemic infection. An asymptom-

presence of known risk factors for significant

atic UTI may be the cause of microscopic hema-

disease in patients with hematuria, such as a

turia23; however, these patients should still

smoking history, occupational exposure

to

undergo urological investigation to exclude