Hematuria

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Basics

Description

Gross (visible) or microscopic (nonvisible) blood in the urine, either symptomatic or asymptomatic

Epidemiology

Prevalence
  • Children: gross: 0.13%; asymptomatic microscopic hematuria (AMH): 0.4–4.1%
  • Adults: AMH: 0.9–17%, depending on population

Etiology and Pathophysiology

  • Trauma
    • Exercise induced (resolves within 24 hours of ceasing activity)
    • Abdominal trauma or pelvic fracture with renal, bladder, or ureteral injury
    • Iatrogenic from abdominal or pelvic surgery, indwelling catheters, or foreign body
    • Physical/sexual abuse
  • Neoplasms
    • Urologic malignancies or benign tumors
    • Endometriosis of the urinary tract (suspect in females with cyclic hematuria)
  • Inflammatory/infectious causes
    • UTI: most common cause of hematuria in adults
    • Renal diseases: radiation nephritis and cystitis, acute/chronic tubulointerstitial nephritis (due to drugs, infections, systemic disease)
    • Glomerular disease
      • Goodpasture syndrome (antiglomerular basement membrane disease; autoimmune; associated pulmonary hemorrhage)
      • IgA nephropathy
      • Lupus nephritis
      • Henoch-Schönlein purpura
      • Membranoproliferative, poststreptococcal, or rapidly progressive glomerulonephritis (GN)
      • Wegener granulomatosis
    • Endocarditis/visceral abscesses
    • Other infections: schistosomiasis, TB, syphilis
  • Metabolic causes
    • Stones (85% have hematuria)
      • Hypercalciuria: common cause of both gross and microscopic hematuria in children
      • Hyperuricosuria
  • Congenital/familial causes
    • Cystic disease: polycystic, solitary renal cyst
    • Benign familial hematuria or thin basement membrane nephropathy (autosomal dominant)
    • Alport syndrome (X-linked in 85%; hematuria, proteinuria, hearing loss, corneal abnormalities)
    • Fabry disease (X-linked recessive inborn error of metabolism; vascular kidney disease)
    • Nail–patella syndrome (autosomal dominant; nail and patella hypoplasia; hematuria in 33%)
    • Renal tubular acidosis type 1 (autosomal dominant or autoimmune)
  • Hematologic causes
    • Bleeding dyscrasias (e.g., hemophilia)
    • Sickle cell anemia/trait (renal papillary necrosis)
  • Vascular causes
    • Hemangioma
    • Arteriovenous malformations (rare)
    • Nutcracker syndrome: compression of left renal vein with renal parenchymal congestion
    • Renal artery/vein thrombosis
    • Arterial emboli to kidney
  • Chemical causes
    • Aminoglycosides, cyclosporine, analgesics, oral contraceptives, Chinese herbs
  • Obstruction
    • Strictures or posterior urethral valves
    • Hydronephrosis from any cause
    • Benign prostatic hyperplasia: Rule out other causes of hematuria.
  • Other causes: loin pain hematuria (most often in young women on oral contraceptives)

Risk Factors

  • Smoking
  • Occupational exposures (dyes, rubber, or tire manufacturing)
  • Medications (e.g., cyclophosphamide, pioglitazone therapy >1 year)
  • Pelvic radiation
  • Chronic infection, especially with calculi
  • Recent upper respiratory tract infection
  • Positive family history of stones, GN, or cancer
  • Chronic indwelling foreign body

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