EM@3AM – Hematuria

Author: Erica Simon, DO, MHA (@E_M_Simon, EMS Fellow, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 56-year-old male, with a previous medical history of smoking (30 pack years) and chronic obstructive pulmonary disease (budesonide), presents to the emergency department for three days of painless hematuria.  The patient denies difficulty voiding.  He denies fevers, chills, unintended weight loss, recent travel, and new sexual partners.  He reports a family history of renal cell carcinoma.

Triage VS: BP 129/87, HR 87, T 99.1 Oral, RR 12, SpO2 94% on room air.

What’s the next step in your evaluation and treatment?

Answer: Hematuria^1-4

• Definition: Abnormal excretion of red blood cells (RBCs) into the urine.
• Classifications:¹
  • Gross hematuria: Visualized as red urine; does not always imply significant blood loss => 1 milliliter of blood may turn urine red.²
    • Clinical presentation: Patients often report dysuria. Urinary retention may occur in the setting of high-volume bleeding (clots obstructing the urethra).
  • Microscopic hematuria: Detection of ≥ 3 RBCs/high-powered field.
    • Clinical presentation:
      • Symptomatic: Dysuria may be reported.
      • Asymptomatic: Literature suggests that as many as 10% of adults and 6% of children in the U.S. may have some degree of microscopic hematuria at any given time.³
    • Pseudohematuria:
      • Urine may appear red, or a urine dipstick may read positive for blood if myoglobin or bilirubin are present in the urine.
      • Red-appearing urine with a negative urine dipstick => food and medication ingestion.
•  Differential Diagnoses: Note: The following lists are not all-inclusive:¹
  • Hematuria in the adult patient:
    • Abdominal aortic aneurysm (AAA), urogenital tract cancer, renal emboli from endocarditis, urethritis, benign prostatic hypertrophy, prostatitis, epididymitis, endometriosis, papillary necrosis, anticoagulation.
  • Hematuria in the pediatric patient:
    • Post-infectious glomerulonephritis (underlying etiology in 10% of pediatric cases⁴), nephrotic syndrome, Henoch Schonlein Purpura, IgA nephropathy, Systemic Lupus Erythematosus, Wilms tumor,
  • Differential diagnoses to be considered in patients of all ages:
    • Trauma, bleeding dyscrasias, polycystic kidney disease, renal arteriovenous malformation, renal vein thrombosis, nephrolithiasis, pyelonephritis, vasculitis, radiation or chemotherapy associated cystitis, schistosomiasis, and tuberculosis.
  • Pseudohematuria:
    • Myoglbinuria: Rhabdomyolysis.
    • Bilirubinuria: Dubin-Johnson Syndrome, Rotor Syndrome.
    • Food ingestion: Beets, rhubarb, berries.
    • Medications: Phenytoin, phenazopyridine, rifampin, quinine sulfate.
•  Evaluation:
  • Assess ABCs and obtain vital signs (VS).
  • Perform a thorough history (to include social and family history) and physical exam. Depending upon the age of the patient, question the individual specifically regarding:
    • Carcinoma risk factors (e.g. smoking, exposure to chemicals, etc.), B type symptoms, AAA risk factors, travel history, history of recent viral illness, and sexual activity.
  • Perform a medical reconciliation.
  • Utilize the history and physical to direct laboratory/imaging evaluation:
    • Urine dipstick, microscopic urinalysis, urine culture, renal function panel, electrolytes, type and cross vs. type and screen, etc.
    • US vs. CT

•  Treatment: Address the underlying etiology.
•  Disposition:¹
  • Indications for urology consultation and admission for gross hematuria:
    • Unstable VS
    • Symptomatic anemia
    • Heavy hematuria with clots (recurrent ED catheter occlusion following saline irrigation)
    • Urinary retention/renal failure
    • Coagulopathy
    • Severe comorbidity
    • Uncontrolled pain or vomiting
  • Safe to discharge to PCM or specialty follow-up:
    • Emergency conditions considered and excluded – hematuria not consistent with:
      • Sepsis secondary to a urinary source
      • Obstructing ureteral stone with urinary tract infection and/or renal insufficiency
      • Condition progressing toward renal failure
      • Coagulopathy with multiple sites of bleeding
      • Traumatic injury
      • Renal vein thrombosis or embolic phenomena
      • Ruptured/Expanding AAA

• Pearls:
  • In the pediatric population, asymptomatic microscopic hematuria mandates a blood pressure assessment => hypertension + microscopic hematuria may be indicative of glomerulonephritis, obstructive uropathy, or other systemic disease.^3,4
  • All patients with microscopic hematuria should be referred for follow-up: repeat urinalysis within 7 days of ED discharge advised.¹

 References:

1. Delgado M, and Delgado E. Hematuria. In Emergency Medicine: Clinical Essentials. 2^nd ed. Philadelphia, Saunders. 2013; 113:984-989.e1
2. Hicks D, and Li C. Management of macroscopic hematuria in the emergency department. Emerg Med J. 2007; 24:385-390.
3. Tu W, and Shortlife L. Evaluation of asymptomatic atraumatic hematuria in children and adults. Nat Rev Urol. 2010; 7:189-194.
4. Davis I, and Avner E. Clinical evaluation of the child with hematuria. In Nelson Textbook of Pediatrics. Philadelphia, Saunders. 2007:2170-2173.

For Additional Reading:

Doc I Can’t Pee, What Could It Be? Evaluation and Management of Acute Urinary Retention in the Emergency Department