Computed Tomography (CT)

significant proteinuria or hypertension).

CT with contrast delivers optimal visualization

Serum immunological investigations are indi-

cated if there is a suspicion of an underlying

of the urinary

anatomy while a noncontrast

immunological cause of renal disease-related

CT is useful if renal calculi are suspected.42-44

hematuria.

Ideally, several CT phases should be used includ-

ing (1) noncontrast phase to detect stones, (2)

portal venous and arterial phases for renal

Nonurological/Intrinsic Renal Causes of

lesions, and (3) excretory phase for intraluminal

Hematuria

pathology (UCC of the ureter or renal pelvis).45,46

However, a CT is more expensive and carries a

Intrinsic nephrological causes

of hematuria

higher radiation exposure than an IVU or USS,

should be considered if urological investigations

and thus should be used with caution when

fail to identify pathology. Nephrological causes

looking for disease in patients with a low inci-

are more common in younger patients and those

dence. The replacement of both USS and IVU by

with proteinuria or hypertension. Frank hema-

CTU is becoming more widely adopted.

turia and concomitant upper respiratory tract

Retrograde Urogram Studies

infection could suggest glomerulonephritis and

it is often appropriate to refer these patients for

Retrograde studies usually require anesthesia

renal assessment rather than delay with urologi-

cal investigations.

and involve direct cannulation of the ureteric

It is important to measure the patients’ blood

orifice with retrograde injection of contrast

pressure during their hematuria clinic consul-

media under

radiological

screening.

This

tation, and

the

urinalysis

should investigate

investigation is particularly

useful for

the

the presence of proteinuria, while urine should

evaluation of equivocal filling defects seen on

be sent for

formal microscopy in order to

an IVU, and it may be combined with upper

investigate

the

presence

of

urinary casts.

urinary tract endoscopy in order to obtain cel-

Patients with proteinuria on dipstick urinaly-

lular brushings or histology of suspicious

sis should have urine sent for protein:creatinine

upper tract lesions. This procedure is highly

ratio (PCR) or albumin:creatinine ratio (ACR)

invasive and should be reserved for selected

measurement and their glomerular filtration

cases of hematuria with a sufficient index of

rate (creatinine clearance) measured. Further

suspicion.

nephrological evaluation may include a renal

Magnetic Resonance Imaging (MRI)

biopsy in order to identify an intrinsic renal

cause of hematuria.

An MRI of the pelvis is indicated if a solid-

appearing bladder cancer is visualized at the

Intractable Hematuria

time of flexible cystoscopy in order to provide

radiological staging information. Ideally, the

Patients with advanced urological malignancy

MRI should be performed prior to the transure-

thral resection of an invasive-looking bladder

and following radiotherapy may develop intrac-

tumor. If the MRI is performed after transure-

table hematuria leading to anemia and clot

thral resection, an interval of at least 4 weeks is

retention. Various palliative options are avail-

required between the resection and the MRI

able to try and ease the hematuria including a

scan in order to prevent inaccurate radiological

“toilet” transurethral resection of their tumor,

upstaging of the bladder mass as a result of

palliative radiotherapy for malignancy, radio-

changes occurring as a result of the surgical

logical internal iliac embolization or intravesi-

resection.

cal instillation of chemicals such as alum or

formalin. Palliative cystectomy may be per-

Additional Tests and Renal Biopsy

formed as a last resort for intractable hematuria

in selected patients. Transurethral resection may

A renal biopsy is indicated when there is evi-

also be helpful to reduce hematuria due to

dence of renal parenchymal disease (such as

advanced prostate cancer. Patients with renal

tumors causing intractable hematuria may be

2.

Khadra MH et al.A prospective analysis of 1,930 patients

successfully

palliated

with

radiotherapy or

with hematuria to evaluate current diagnostic practice.

radiological embolization. Hematuria following

J Urol. 2000;163(2):524-527

3.

Nishikawa Y et al. Clinical assessment of patients with

radiotherapy should always be investigated with

microscopic hematuria pointed out by mass screening

cystoscopy, as in these patients there is an

examination. Hinyokika Kiyo. 1992;38(6):647-651

increased risk of malignancy.

4.

Grossfeld GD, Carroll PR. Evaluation of asymptomatic

microscopic hematuria. Urol Clin North Am. 1998;25(4):

661-676

Loin Pain Hematuria Syndrome

5.

Grossfeld GD et al. Evaluation of asymptomatic micro-

Association best practice policy–part II: patient evalua-

scopic hematuria in adults: the American Urological

The term “loin pain hematuria syndrome” is

tion, cytology, voided markers, imaging, cystoscopy,

nephrology evaluation, and follow-up. Urology. 2001;

given to describe a condition whereby patients

6.

57(4):604-610

experience loin pain associated with hematuria,

Grossfeld GD et al. Asymptomatic microscopic hematu-

ria in adults: summary of the AUA best practice policy

but in whom no identifiable cause is found. The

recommendations. Am Fam Physician. 2001;63(6):

condition is commoner in women than men and

1145-1154

may

persist

for

many

years. No pathological

7.

Briganti E, McNeil J, Atkins R. The epidemiology of dis-

cause is found following full hematuria investi-

eases of the kidney and urinary tract: an Australian

perspective. Report to the Board of the Australian

gations including renal biopsy and angiography.

Kidney Foundation [online]. http://www.med.monash.

edu.au/epidemiology/general_info/disease_kidney.

html. 2001

Follow-Up for Patients with

8.

Ritchie CD, Bevan EA, Collier SJ. Importance of occult

haematuria found at screening. Br Med J (Clin Res Ed).

Hematuria in the Absence of

1986;292(6521):681-683

9.

Scottish Intercollegiate Guidelines Network. Investi-

Demonstrable Pathology

gation of asymptomatic microscopic haematuria in

adults. www.sign.ac.uk/pdf/sign17.pdf. 1997

10.

McDonald MM, Swagerty D, Wetzel L. Assessment of

Some patients with a negative initial urologi-

microscopic hematuria in adults. Am Fam Physician.

2006;73(10):1748-1754

cal evaluation eventually develop significant

11.

Sokolosky MC. Hematuria. Emerg Med Clin North Am.

urological or renal disease; therefore, patients

2001;19(3):621-632

with

negative

initial

investigations require

12.

Cohen RA, Brown RS. Clinical practice. Microscopic

adequate follow-up, usually in a primary care

hematuria. N Engl J Med. 2003;348(23):2330-2338

13.

U.S. Preventive Series Task Force. Guide to Clinical

setting. This follow-up is important if the

Preventive Series. Alexandria, VA: International Medical

patient has risk factors for the development of

Publishing; 1996

urological47 or renal pathology. Patients with

14.

Sultana SR et al. Microscopic haematuria: urological

microscopic hematuria should undergo repeat

investigation using a standard protocol. Br J Urol. 1996;

urinalysis and

referral to a

renal physician

78(5):691-696; discussion 697-698

15.

Benbassat J et al. Symptomless microhaematuria in

should be considered if the patient develops

schoolchildren: causes for variable management strate-

hypertension, significant proteinuria or evi-

gies. Q J Med. 1996;89(11):845-854

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16.

Renal Association and British Association of Urological

of macroscopic hematuria in a patient who has

Surgeons. Joint consensus statement on the initial

assessment of haematuria. 2008

previously been evaluated for microscopic

17.

Khan MA, Shaw G, Paris AM. Is microscopic haematuria

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Schroeder GL et al. A side by side comparison of cytol-

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Friedman GD et al. Can hematuria be a predictor as well

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