haematuria

• rapid and relatively sensitive (>80%)

• haemaglobin

• myoglobin: rush, rhabdomyolysis, myositis

• therefore spec range 65-99%

• trace = negative

macroscopic (visible)

• associated with urological conditions

• consider:

  • haemoglobinuria

    • haemolytic anaemia

  • myoglobinuria

    • rhabdomyolysis

  • beeturia (after eating beetroot)

  • prophyria

  • medicines

    • rifampicin

    • chlorpromazine

• if UTI ruled out

  • refer urology and cystoscopy or nephrology with no risk factors

microscopic (non visible)

• transient microscopic = common

• reported in 39% of people

• mixture of urological and glomerular causes

• persistent microscopic haematuria = urine positive on 2/3 consdectuive dipsticks (1-2 week)

• once benign causes ruled out:

  • UTI

  • exercise

  • menstruation

• imaging

• if >40 urological assessment or risk factors

• assess prostate

• investigatiosn

  • BP

  • renal function

    • eGFR

    • ACR

    • urine microscopy for urinary casts and dysmorphic red cells

referral to renal:

• eGFR \<30

• eFGR declining by >5mL in previous year or >10mL/min over last 5 years

• uncontrolled hypertension ≥ 140/90

• Unexplained visible heamaturia following urological assessment where no cause found

Assessment

• symptomatic/asymptomatic

  • dysuria

  • frequence

  • urgency

  • hesitancy

• anti-coagulant/anti-platelet medicines more likely to exacerbate compared to cause haematuria

• urine cytology probably not useful

  • definatley not as part of routine investigation

  • low sensitiveity

red flags

• history of recurrent macroscopic haematuria

• age >40

• current smoker or recent histoyr of smoking

• history of recurrent UTI or other urological disorders

• occupational exposure to chemicals/dyes

• Previous pelvic irradiation

• history of excessive analgeisa

• cyclophosphamide

• bladder cancer

• family histoyr

• smoking

• male

• occupational

Imaging

• CTU = gold standard in investigation of haematuria

  • 3 phases:

    • non contrast - stones

    • contrast - structural, vascular, infectious abnormal of parenchyma

    • delayed excretory phase

    • = triphasic CT

    • sens for renal stones = 94-98%

    • superior to uss and ivu for detecting renal masses

Proteinuria

• urine dipstick - highly specific but lacks sensitivity

• ACR more sensitive (better than PCR)

• spot accurately reflects 24hr albuminuria and proteinuria

• false positive

  • alkaline urine (pH >7)

  • gross haematuria

  • mucus

  • semen or leukocytes

• transient

  • exercise

  • standing for long periods

  • pregnnacy

  • uti

  • acute febrile illness

  • CHF

• persistent

  • do ACR (or PCR)

• manage in primary care if:

  • ACR \< 70 (or PCR \<100)

    • haematuria absent

    • eGFR ≥ 30mL/min

  • BP, urinalysis, renal function every 6-12 mo

  • HTN \<130/80

• routine referral to nephrology:

  • ACR >70 or PCR >100

  • haematuria present and ACR >30 or PCR >50

  • eGFR \< 30

• urgent

  • ACR ≥ 250 or PCR ≥ 300