Hematuria - ClinicalKey

24/9/23, 21:56 Hematuria - ClinicalKey
CLINICAL OVERVIEW
Hematuria
Elsevier Point of Care (see details)
Updated May 27, 2022. Copyright Elsevier BV. All rights reserved.
Synopsis
Urgent Action 3
Patients with clot retention or gross hematuria with hemodynamic compromise may
require replacement of fluids and blood, correction of bleeding diathesis, reversal of
anticoagulants, and/or continuous bladder irrigation
Must identify source of bleeding; vascular phase CT is usually imaging study of choice
Cystoscopy may be required urgently if clots cannot be cleared by irrigation, urine

output is decreased, or bladder becomes distended
Rarely, uncontrolled bleeding from the bladder fails to respond to conservative therapy
and requires emergent cystectomy; uncontrolled bleeding from the kidney may require
nephrectomy or selective angiography and embolization
Key Points
Hematuria may present as macroscopic (gross) hematuria or microscopic hematuria and may
be symptomatic or asymptomatic
Gross hematuria is considered to be caused by malignancy until proven otherwise
Seek common causes of hematuria, including urinary tract infection, kidney calculi, and
infection-related glomerulonephritis (or IgA nephropathy)
https://www-clinicalkey-com.uandes.idm.oclc.org/#!/content/clinical_overview/67-s2.0-54490e0e-c9b7-4046-8acd-1fedb4d030fd 1/23
Use urinalysis to confirm hematuria (both macroscopic and microscopic) and to determine
whether blood has a glomerular (nephrologic) or nonglomerular (urologic) origin by
morphologic characteristics
Imaging is recommended to identify possible malignancy or urolithiasis and to evaluate

trauma. Selection of CT and/or ultrasonography is based on patient age and circumstances (eg,
symptoms suggesting urolithiasis, known or suspected trauma) and risk of malignancy 1
Cystoscopy is performed for all patients older than 35 years who have asymptomatic
microhematuria or unexplained gross hematuria and for patients of any age with risk factors
for malignancy 2
Treatment is directed toward the underlying cause of hematuria, once known; refer patient to
either urologist or nephrologist
Pitfalls
Routine therapy with warfarin or antiplatelet therapy usually does not cause microhematuria.
Evaluate patients on antiplatelet or anticoagulation therapy who have asymptomatic
microhematuria in the same way as other patients, regardless of type or level of anticoagulation
4
There is less risk of finding an abnormality in patients with anticoagulation and gross
hematuria than in patients with gross hematuria who do not have anticoagulation, but the risk
is present and these patients should be evaluated
Terminology
Clinical Clarification
Hematuria is the presence of an abnormal quantity of RBCs in the urine 5
Classification
Microscopic hematuria is the presence of 3 or more RBCs per high-power field in a single
properly collected, centrifuged urine specimen 6
Glomerular hematuria originates in the glomeruli 5
Nonglomerular hematuria originates from the renal pelvis, ureter, or bladder 5
Macroscopic (gross) hematuria is urine that is discolored by blood, detectable by the naked eye
5
Diagnosis
Clinical Presentation
History
Symptoms at presentation
Microscopic or macroscopic hematuria can occur as an isolated finding, or it can be

accompanied by additional symptoms suggestive of its cause
Microscopic hematuria is often discovered incidentally, whereas gross hematuria usually

prompts an emergency department or urgent care visit
As little as 1 mL of blood in 1 L of urine will cause visible discoloration 5
Painless macroscopic hematuria is regarded as a symptom of cancer until proven otherwise
Macroscopic hematuria occurs in up to 85% of patients with bladder cancer and up to

40% of patients with renal cell carcinoma 7
Accompanying symptoms that can indicate underlying source or cause
Urinary tract infection symptoms, including:
Fever and chills
Dysuria
Suprapubic discomfort
Urinary frequency
Lower urinary tract irritative symptoms (eg, urgency, frequency, dysuria) often accompany
gross hematuria, regardless of its cause
Bleeding from other sites might indicate bleeding diathesis or coagulopathy
Severe flank pain can indicate urolithiasis or pyelonephritis
Clots are almost always associated with a urologic origin
Portion of the urinary stream demonstrating gross hematuria during voiding gives clues about
location of bleeding within the urinary tract
Initial hematuria (start of voiding) indicates bleeding from the anterior urethra
Terminal hematuria (end of voiding) is consistent with bleeding from the posterior urethra,
bladder, trigone, or neck
Total hematuria (throughout voiding) indicates bleeding at or above bladder level
History can include any of the following:

Recent ingestion of certain foods or drugs, urinary instrumentation, vigorous exercise, or
current menstruation
Could indicate benign causes of hematuria or (in the case of certain foods or drugs)
discoloration that looks like (but is not) hematuria
Streptococcal cellulitis or upper respiratory tract infection associated with

glomerulonephritis
Precedes hematuria
Polycystic kidney disease or medullary sponge kidney
Conditions or diseases that cause hypercalciuria
Urinary tract endometriosis
Accompanies cyclic hematuria
Sickle cell trait or disease
More common in Black patients
Travel to the Middle East or Africa
Could indicate schistosomiasis
Patients with associated renal failure may have symptoms related to fluid overload (eg,
dyspnea, edema) or anemia (eg, palpitations, lightheadedness, fatigue)
Consider common conditions that cause micro- or macroscopic hematuria first
Urinary tract infection (25% of all cases of atraumatic hematuria; 50% of cases in children)
(Related: Urinary Tract Infection in Adults) 7
Suprapubic discomfort (Related: Urinary Tract Infection in Children)
Urinary frequency
Dysuria
Urolithiasis (20% of all cases of atraumatic hematuria) (Related: Nephrolithiasis) 7
Acute onset of severe, colicky flank pain
Accompanied by nausea and vomiting

Uncommon conditions causing hematuria can be suggested by additional history
Infection-related glomerulonephritis (eg, postinfectious glomerulonephritis,

poststreptococcal glomerulonephritis)
Suggested by a recent skin or upper respiratory tract infection with hematuria after 10 to
21 days
IgA nephropathy is suggested if hematuria occurs earlier than 10 days after infection of the
upper respiratory tract or other infection (usually 1-2 days after infection develops)
Hypercalciuria in children (30% incidence in children with isolated hematuria [only

hematuria, no proteinuria]) 8
May be asymptomatic
Symptoms when present include frequency, urgency, incontinence, dysuria, and

abdominal and flank pain
Requires laboratory evaluation using spot urinary calcium to creatinine ratio
Physical examination
Examination results may be normal or may include findings specific to the underlying cause
Physical findings of common conditions that cause hematuria

Urinary tract infection
Fever
Suprapubic or flank tenderness
Urolithiasis
Diaphoresis
Flank tenderness
Poststreptococcal glomerulonephritis (Related: Poststreptococcal Glomerulonephritis)
Flank or back tenderness from renal capsule swelling
Hypertension
Edema
Various findings associated with rare causes of hematuria 9
Hypertension: associated with nephritic syndrome and renal vascular disease
Edema and hypertension: consistent with glomerulonephritis and renal insufficiency
New cardiac murmur: suggests subacute bacterial endocarditis (risk factor for renal embolic
disease and immune complex glomerulonephritis)
Irregular heart rate of atrial fibrillation (risk factor for renal artery thrombosis/embolism)
Palpable flank or abdominal mass: can signify renal cancer
Enlarged or nodular prostate
Growth restriction with failure to thrive in children: possible chronic kidney disease
Causes and Risk Factors
Causes
Origin can be either glomerular or nonglomerular
Typically, microscopic hematuria is glomerular in origin and macroscopic hematuria is

nonglomerular (urologic)
No cause is found in approximately 60% of patients 10
Most common causes of hematuria:
Urinary tract infection (Related: Urinary Tract Infection in Adults)
Bladder cancer (Related: Bladder Cancer)
Intrinsic renal disease (Related: Chronic Kidney Disease)
Urolithiasis (Related: Nephrolithiasis)
Most common causes of glomerular hematuria include IgA nephropathy and thin basement
membrane disease (Related: Sickle Cell Disease)
Causes of hematuria.
Glomerular
Primary glomerulonephritis
• Alport syndrome
• Thin basement membrane disease
• IgA nephropathy
• Pauci-immune (ANCA-related) vasculitis/anti–glomerular basement membrane disease
Secondary glomerulonephritis
• Henoch-Schönlein purpura
• Systemic lupus erythematosus
• Infection-related glomerulonephritis
• Thrombotic microangiopathies (eg, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome,
scleroderma renal crisis, malignant hypertension)
Associated with other glomerular pathology
• Diabetic nephropathy
• Focal segmental glomerular sclerosis
• Minimal change disease
• Membranous nephropathy
Tubular/interstitial
• Interstitial nephritis
• Papillary necrosis
• Analgesic nephropathy
• Pyelonephritis
Structural kidney disease–related
• Acquired or hereditary cystic disease
• Medullary sponge kidney
Vascular
• Renal vein thrombosis

• Renal infarct/necrosis
• Arteriovenous malformations
• Nutcracker syndrome
Urothelial
• Malignancy (involving the kidney, ureters, bladder, or prostate)
• Nephrolithiasis
• Nephrocalcinosis
• Hypercalciuria
• Strictures
• Indwelling catheters
• Benign prostatic hypertrophy
• Bladder or ureteral polyps
Medications
• Cyclophosphamide/ifosfamide
• Anticoagulation associated
Other, not rare
• Infectious (pyelonephritis, cystitis, urethritis, prostatitis, schistosomiasis, tuberculosis, polyoma virus)
• Rejection or trauma in a kidney transplant
• Pelvic radiation
• Bleeding disorders: sickle cell disease, sickle cell trait, hemophilia A or B, thrombocytopenia
• After instrumentation of the urinary tract or trauma
• Contamination from menstrual bleeding
Rare
• Endometriosis of the urinary tract

• Loin pain hematuria syndrome
Risk factors and/or associations
Age
Patients older than 35 years are at increased risk for the development of a urinary tract
malignancy 2
Sex
Males are at higher risk for hematuria to be caused by malignancy
Genetics
Hematuria may occur in association with several genetic disorders
Benign familial hematuria (OMIM #141200) 11
Autosomal dominant disorder manifested as nonprogressive isolated microscopic

hematuria that does not result in renal failure
Caused by heterozygous mutations in the COL4A3 or the COL4A4 genes, encoding alpha
chains for type IV collagen
Sickle cell disease (OMIM #603903) (Related: Sickle Cell Disease) 12 13
Autosomal recessive disorder characterized by intermittent vasoocclusive events and

chronic hemolytic anemia; micro- and macroscopic hematuria are common
manifestations of renal abnormalities
Caused by mutations in the HBB gene, encoding β-globin
Alport syndrome 12 (OMIM #301050) 14
Most often an X-linked inherited disorder caused by mutations in COL4A5, encoding α-5
chain of type IV collagen
Hematuria during the first year of life and hearing loss in late childhood
Kidney calculi may be familial and may be linked to a specific gene (eg, X-linked
nephrolithiasis) (Related: Nephrolithiasis)
Other risk factors/associations

Common risk factors for urothelial malignancy in patients with hematuria
Occupational exposure to chemicals or dyes (benzenes or aromatic amines)

Past or current cigarette smoking
Overuse of analgesics (eg, aspirin, NSAIDs)
History of gross hematuria
History of pelvic irradiation
History of irritative voiding symptoms
History of urologic disorder
History of chronic urinary tract infection
History of chronic indwelling foreign body
Exposure to carcinogenic agents or chemotherapy (eg, alkylating agents)
Family history of urothelial cancer or Lynch syndrome 6
Antithrombotic medications may trigger hematuria (evaluation still required)
Among anticoagulants and antiplatelet agents, warfarin is associated with the greatest risk
but is unlikely to cause major hematuria 15
Novel antithrombotic agents (eg, dabigatran, rivaroxaban, apixaban) are more commonly
associated with major hematuria 15
Diagnostic Procedures
Primary diagnostic tools

Dipstick testing may initially identify blood in the urine,
as it is sensitive enough to detect 1 to 2 RBCs per high-
power field when specimen is examined within 2 hours of
collection 5
Plasma proteins from hematuria may increase protein Asymptomatic microscopic

in the urine to less than 2+ on dipstick testing; hematuria (adult).
however, proteinuria of more than 2+ suggests
glomerular disease 16
Confirm heme-positive results of dipstick testing with

microscopic urinalysis before initiating further
evaluation 4 6
Visible hematuria propensity with
Voided midstream collection is sufficient for most individual anticoagulant or
(discard first 10 mL of urine) antiplatelet agents.
Catheterization may be necessary for the following:
Female patients with obesity
Patients with a Foley or suprapubic catheter
Menstruating patients
Patients who use intermittent catheterization Algorithm of the general approach
to the laboratory and radiologic
evaluation of the patient with
History and physical examination can provide clues to glomerular or extraglomerular
underlying cause of hematuria hematuria. - ANA, antinuclear
antibody; ASO, antistreptolysin O;
Assess risks for genitourinary malignancy, renal BUN, blood urea nitrogen; C3/C4,
disease, and gynecologic and nonmalignant complement; CBC, complete blood
cell count; Cr, creatinine; RBC, red
genitourinary causes 6 blood cell.
Most cases of microscopic and gross hematuria require

further evaluation 17
Cases of microscopic and gross hematuria that do

not require a complete workup, owing to high
likelihood of a benign cause, include the following

(retest after resolution of the condition after a
minimum of 48 hours has elapsed): 2
Preexisting medical renal disease
Menstruation
Microscopic hematuria (pediatric).
Infection/viral illness
Trauma
Recent urologic procedures
Recent vigorous exercise

Evaluation of macroscopic
This exclusion has been challenged 18 hematuria (adult). - UTI, urinary
tract infection.
Finding of 25 RBCs or less per high-power field
in asymptomatic, low-risk females aged 35 to 50
years who are nonsmokers 19
Gross hematuria is considered to be caused by

malignancy until proven otherwise
If urinalysis and physical assessment results suggest a

glomerular cause of hematuria:
Obtain renal function panel, electrolyte levels, CBC,

erythrocyte sedimentation rate or C-reactive protein
level, and serologic tests for glomerular causes of
hematuria; also determine estimated GFR 16 20 21
Obtain throat culture and antistreptolysin O titers if

streptococcal infection is suspected 20
Ultrasonography of the kidneys is the imaging

procedure of choice in adults
Obtain anticoagulation studies on patients receiving
anticoagulants (eg, INR for warfarin therapy) 7
Additional evaluation in adults is based on risk

stratification as low, intermediate, or high risk for
genitourinary malignancy 6
Low risk: either repeat urinalysis within 6 months or pr

ultrasonography
Intermediate risk: obtain cystoscopy and renal ultrasono
High risk: obtain cystoscopy and upper tract imaging (m

urography, or retrograde pyelography is combined with
renal ultrasonography)
Multiphasic CT urography with and without contrast

procedure of choice in high-risk adults to evaluate th
upper tracts 2
Ultrasonography of kidneys and bladder is typically the ini
regardless of suspected source
Laboratory
Imaging
Procedures
Other diagnostic tools 6
Differential Diagnosis
Causes of abnormal urine color other than blood
Red/brown color
Foods
Aloe
Beets
Blackberries
Fava beans
Rhubarb
Medications
Antibiotics (eg, rifampin, metronidazole, nitrofurantoin, sulfonamides)
Antipyretics (eg, salicylates, ibuprofen)
Anticonvulsants (eg, phenytoin)
Laxatives (eg, phenolphthalein, senna)
Antimalarial agents (eg, quinine, chloroquine)
Tranquilizers/sedatives (eg, propofol, chlorpromazine, thioridazine, prochlorperazine)
Miscellaneous (phenazopyridine, methyldopa, levodopa, doxorubicin hydrochloride,

deferoxamine)
Other agents
Globins (eg, myoglobin, hemoglobin)
Porphyrin (eg, lead or mercury poisoning)
Orange
Foods
Carotene-containing foods (eg, carrots, winter squash)
Medications
Pyridium
β-carotene supplements
Vitamin B supplements
Rifampin
Warfarin
Other agents
Urochrome (breakdown product of hemoglobin, responsible for normal yellow color of

urine; dehydration deepens color)
Green/blue
Foods
Asparagus
Medications
Amitriptyline
Cimetidine
Indomethacin
Promethazine
Black
Medications
Methyldopa
Treatment
Goals
Resolve bleeding
Disposition
Admission criteria
Criteria for general admission
Bladder outlet obstruction, particularly in the setting of either of the following:
Renal failure
Hydronephrosis
Hemodynamic instability
Uncontrolled hypertension caused by renal parenchymal disease
Shock
Orthostatic hypotension
Other conditions, associated with the underlying cause
Severe or intractable pain
Severe nausea and vomiting
Severe anemia or bleeding condition
Recommendations for specialist referral

Urologist consultation or referral
Presence of clots
Confirmed gross hematuria, even if self-limited 4
Refer for cystoscopy and imaging those adults with microscopically confirmed hematuria
who do not have some demonstrable benign cause 4
Renal or ureteral calculi with the following:
Evidence of sepsis caused by urinary tract infection
Acute renal failure
Anuria
Intractable pain, nausea, or vomiting
Calculi larger than 10 mm
Hematuria in the presence of risk factors for malignancy
Nephrologist consultation or referral
Acute kidney injury 25
Increase in serum creatinine of 0.3 mg/dL or more
Increase in serum creatinine of more than 50%
Reduction in urine output to less than 0.5 mL/kg/hour for 6 hours
Markedly diminished renal function of unknown duration (GFR less than 60 mL/minute)
Suspected glomerulonephritis
Treatment Options
Treatment is directed toward the underlying cause of hematuria, once it is identified
In the setting of clot retention or gross hematuria with hemodynamic compromise, 1 or more of
the following may be required: 3
IV fluid resuscitation
Packed RBC transfusion
Correction of clotting abnormalities
Urethral catheterization using a wide-bore (minimum 22-French), stiff, 3-way irrigating

catheter that allows continuous bladder irrigation with sterile water or saline
Source of bleeding must be identified; vascular phase CT is usually the imaging study of choice 3
Cystoscopy may be urgently required if clots cannot be cleared by irrigation, urine output is
decreased, or bladder becomes distended
Routine cystoscopy does not require antimicrobial prophylaxis in healthy adults in the absence
of infectious signs and symptoms 26
If indicated, empiric prophylactic antibiotic coverage with single dose of amoxicillin-

clavulanate or sulfamethoxazole-trimethoprim 26
Rarely, uncontrolled bleeding from the bladder fails to respond to conservative therapy, requiring
emergent cystectomy; uncontrolled bleeding from the kidney may require nephrectomy or
selective angiography and embolization 3
Nondrug and supportive care
Procedures
Bladder irrigation 3
General explanation
A 3-way catheter is placed in the bladder
Lumen 1 allows for balloon inflation to keep the catheter in place
Lumen 2 provides a channel for instillation of saline or other fluid for irrigation
Lumen 3 allows outflow
Indication
Gross and persistent hematuria with hemodynamic impact
Clots resulting in urinary retention
Cystectomy 3
General explanation
Removal of all or part of the bladder, with construction of a urinary diversion
Extent of resection depends on cause of bleeding and presence (and depth) or absence of
malignancy
Indication
Intractable and uncontrollable bladder hemorrhage
Embolization 3
General explanation
Angiography is performed to localize the bleeding vessel, and a catheter is guided to the site to
deliver the embolus
Indication
Refractory bleeding from the kidney with visualization of a culprit vessel amenable to
embolization
Nephrectomy 3
General explanation
Partial or complete resection of a kidney
Indication
Refractory, uncontrollable hematuria confirmed to originate from the kidney
Monitoring
After a negative urologic workup, repeat urinalysis within 12 months 6
If that urinalysis is negative, may stop monitoring
If urinalysis is persistently positive for hematuria, engage in shared decision making

regarding ongoing evaluation
If patients with negative findings on prior hematuria evaluation develop gross hematuria,
significant increase in degree of microscopic hematuria, or new urologic symptoms, initiate
further evaluation
Complications and Prognosis
Prognosis
Variable
Persistent asymptomatic isolated microscopic hematuria in patients aged 16 to 25 years is

associated with increased risk of end-stage renal disease for 22 years, although incidence and
absolute risk are low 27
Urinary tract malignancy rate for microscopic hematuria is greater than 2% 24
The earlier bladder cancer is detected, the better the prognosis (stage I 5-year survival is
88%, whereas stage IV 5-year survival is 15%) 24
Urinary tract malignancy rate for gross hematuria is 25% 28
References
1. American College of Radiology: ACR Appropriateness Criteria: Hematuria--Child. ACR website. Revised
2018. Accessed January 21, 2022. https://acsearch.acr.org/docs/69440/Narrative/
View In Article (https://www-clinicalkey-com.uandes.idm.oclc.org/#!/content/clinical_overview/67-s2.0-54490e0e-c9b7-
4046-8acd-1fedb4d030fd#inline-reference-1) | Cross Reference (https://acsearch.acr.org/docs/69440/Narrative/)
2. Davis R et al: Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA
guideline. J Urol. 188(6 suppl):2473-81, 2012
4046-8acd-1fedb4d030fd#inline-reference-2) | Cross Reference (https://pubmed.ncbi.nlm.nih.gov/23098784)
3. Fragkopoulou C et al: Haematuria. Surgery (Oxford). 31(10):509-15, 2013

4046-8acd-1fedb4d030fd#inline-reference-3) | Cross Reference (https://doi-
org.uandes.idm.oclc.org/10.1016/j.mpsur.2013.08.005)
4. Nielsen M et al: Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the
American College of Physicians. Ann Intern Med. 164(7):488-97, 2016
5. Jimbo M: Evaluation and management of hematuria. Prim Care. 37(3):461-72, vii, 2010
6. Barocas DA et al: Microhematuria: AUA/SUFU guideline. J Urol. 204(4):778-86, 2020

7. Sokolosky MC: Hematuria. Emerg Med Clin North Am. 19(3):621-32, 2001
8. Parekh DJ et al: The association of an increased urinary calcium-to-creatinine ratio, and asymptomatic
gross and microscopic hematuria in children. J Urol. 167(1):272-4, 2002
9. Margulis V et al: Assessment of hematuria. Med Clin North Am. 95(1):153-9, 2011

10. Bryant RJ et al: Haematuria. Surgery (Oxford). 26(4):150-3, 2008

org.uandes.idm.oclc.org/10.1016/j.mpsur.2008.02.003)
11. Hematuria, Benign Familial; BFH. Online Mendelian Inheritance in Man. OMIM website. Johns
Hopkins University. Updated May 27, 2010. Edited June 21, 2016. Accessed January 21, 2022.
https://www.omim.org/entry/141200
4046-8acd-1fedb4d030fd#inline-reference-11) | Cross Reference (https://www.omim.org/entry/141200)
12. Kazi SN et al: Work-up of hematuria. Prim Care. 41(4):737-48, 2014

13. Sickle Cell Anemia. Online Mendelian Inheritance in Man. OMIM website. Johns Hopkins University.
Updated March 8, 2021. Edited March 8, 2021. Accessed January 21, 2022.
14. Alport Syndrome 1, X-Linked; ATS1. Online Mendelian Inheritance in Man. OMIM website. Johns
Hopkins University. Updated July 10, 2015. Edited August 2, 2019. Accessed January 21, 2022.
15. Bhatt NR et al: Incidence of visible hematuria among antithrombotic agents: a systematic review of over
175,000 patients. Urology. 114:27-32, 2018
16. Pan CG: Evaluation of gross hematuria. Pediatr Clin North Am. 53(3):401-12, vi, 2006
17. Linder BJ et al: Guideline of guidelines: asymptomatic microscopic haematuria. BJU Int. 121(2):176-83,
2018
18. Akiboye RD et al: Haematuria in sport: a review. Eur Urol Focus. 5(5):912-6, 2019
19. American College of Obstetricians and Gynecologists et al: Committee Opinion No. 703: asymptomatic
microscopic hematuria in women. Obstet Gynecol. 129(6):e168-72, 2017
20. Hahn RG et al: Evaluation of poststreptococcal illness. Am Fam Physician. 71(10):1949-54, 2005
21. Thaller TR et al: Evaluation of asymptomatic microscopic hematuria in adults. Am Fam Physician.
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22. Niyyar VD et al: Point-of-care ultrasound in the practice of nephrology. Kidney Int. 93(5):1052-9, 2018
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Accessed January 21, 2022. https://acsearch.acr.org/docs/69490/Narrative/
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urological malignancy. J R Coll Surg Edinb. 47(1):422-7, 2002
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24/9/23, 21:56 Hematuria - ClinicalKey

Cystoscopy may be required urgently if clots cannot be cleared by irrigation, urine

Gross hematuria is considered to be caused by malignancy until proven otherwise

Imaging is recommended to identify possible malignancy or urolithiasis and to evaluate

Glomerular hematuria originates in the glomeruli 5

Nonglomerular hematuria originates from the renal pelvis, ureter, or bladder 5

Microscopic or macroscopic hematuria can occur as an isolated finding, or it can be

Microscopic hematuria is often discovered incidentally, whereas gross hematuria usually

As little as 1 mL of blood in 1 L of urine will cause visible discoloration 5

Painless macroscopic hematuria is regarded as a symptom of cancer until proven otherwise

Macroscopic hematuria occurs in up to 85% of patients with bladder cancer and up to

Urinary tract infection symptoms, including:

Fever and chills

Bleeding from other sites might indicate bleeding diathesis or coagulopathy

Severe flank pain can indicate urolithiasis or pyelonephritis

Clots are almost always associated with a urologic origin

Total hematuria (throughout voiding) indicates bleeding at or above bladder level

History can include any of the following:

Streptococcal cellulitis or upper respiratory tract infection associated with

Polycystic kidney disease or medullary sponge kidney

Conditions or diseases that cause hypercalciuria

Urinary tract endometriosis

Accompanies cyclic hematuria

Sickle cell trait or disease

More common in Black patients

Travel to the Middle East or Africa

Could indicate schistosomiasis

Consider common conditions that cause micro- or macroscopic hematuria first

Suprapubic discomfort (Related: Urinary Tract Infection in Children)

Urolithiasis (20% of all cases of atraumatic hematuria) (Related: Nephrolithiasis) 7

Acute onset of severe, colicky flank pain

Accompanied by nausea and vomiting

Infection-related glomerulonephritis (eg, postinfectious glomerulonephritis,

Hypercalciuria in children (30% incidence in children with isolated hematuria [only

Symptoms when present include frequency, urgency, incontinence, dysuria, and

Requires laboratory evaluation using spot urinary calcium to creatinine ratio

Physical findings of common conditions that cause hematuria

Suprapubic or flank tenderness

Poststreptococcal glomerulonephritis (Related: Poststreptococcal Glomerulonephritis)

Flank or back tenderness from renal capsule swelling

Various findings associated with rare causes of hematuria 9

Hypertension: associated with nephritic syndrome and renal vascular disease

Edema and hypertension: consistent with glomerulonephritis and renal insufficiency

Palpable flank or abdominal mass: can signify renal cancer

Enlarged or nodular prostate

Causes and Risk Factors

Typically, microscopic hematuria is glomerular in origin and macroscopic hematuria is

No cause is found in approximately 60% of patients 10

Most common causes of hematuria:

Urinary tract infection (Related: Urinary Tract Infection in Adults)

Bladder cancer (Related: Bladder Cancer)

Intrinsic renal disease (Related: Chronic Kidney Disease)

Urolithiasis (Related: Nephrolithiasis)

• Renal vein thrombosis

• Endometriosis of the urinary tract

Risk factors and/or associations

Benign familial hematuria (OMIM #141200) 11

Autosomal dominant disorder manifested as nonprogressive isolated microscopic

Sickle cell disease (OMIM #603903) (Related: Sickle Cell Disease) 12 13

Autosomal recessive disorder characterized by intermittent vasoocclusive events and

Caused by mutations in the HBB gene, encoding β-globin

Alport syndrome 12 (OMIM #301050) 14

Other risk factors/associations