CAUSES :
1. RENAL
- TRAUMA
- TUMORS LIKE HYPERNEPHROMA, WILMS TUMOR , ADENOMA , ANGIOMA , PAPILLOMA , SQUAMOUS CELL CARCINOMA
- CALCULUS
- GLOMERUNEPHRITIS
- POLYCYSTIC KIDNEYS
- TUBERCULOSIS
- PYELONEPHRITIS
- INFARCTION
- POLYARTERITIS NODOSA
- CHR INTERSTITIAL NEPHRITIS
- HYDRONEPHROSIS
- IRRADIATION NEPHRITIS
- HYDATID DISEASE
- MEDULLARY SPONGE KIDNEY
- RELIEF OF TENSION BY THE SUDDEN EMPTYING OF BLADDER IN CASE OF CHR RETENSION URINE
- INFECTIVE ENDOCARDITIS
- SHUNT NEPHRITIS IN CASE OF HYDROCEPHALUS PATIENTS
- BERGERS NEPHRITIS ( IGA DISEASE )
- RENAL VEIN THROMBOSIS
- POSTURAL PROTEINURIA
- JOGGERS NEPHRITIS
- ANEURYSM OF RENAL ARTRY
- INTRARENAL ARTERIOVENOUS FISTULA
2. URETERIC CAUSES
- CALCULUS
- TUMORS LIKE PAPILLOMA , CARCINOMA
3. VESICAL
- TRAUMA
- TUMORS LIKE PAPILLOMA OR PAPILLARY CARCINOMA, SARCOMA, HAEMANGIOMA
- PROSTATIC ENLARGEMENT
- TUBERCULOSIS
- CALCULUS
- CYSTITIS
- RADIATION CYSTITIS
- VESICLE SCHISTOSOMIASIS
- FOREIGN BODY
- DISEASE OF ADJACENT ORGANS
4. URETHRAL
- URETHRITIS
- CALCULUS
- TUMORS
- FOREIGN BODY
- CARUNCLE
5. GENERAL OR OTHERS
- DRUGS LIKE NSAIDS, ANTICOAGULANTS
- BLEEDING DISORDERS
- EPIDIDYMITIS
- CYSTINURIA CAUSING STONE
- CHRONIC SEPSIS
- HENOCH SCHONLEIN SYNDROME
- ALPORTS SYNDROME
- SLE
- SICKLE CELL DISEASE
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2 ND CLASSIFICATION OF CAUSES :
CAUSES
1. Trauma
. Exercise-induced (resolves with rest)
. Abdominal trauma with renal or ureteral injury
. Pelvic fracture with bladder or urethral injury
. Iatrogenic trauma after catheterization, abdominal, or pelvic surgery
. Foreign body, physical/sexual abuse
2. Neoplasms
. Malignancies of prostate, urethra, bladder, ureter, kidney may present with hematuria (30% of patients with gross hematuria will have a malignancy, 5% of patients with microscopic hematuria)
. Benign tumors
. Endometriosis of the urinary tract (suspect in females with cyclic hematuria)
3. Inflammatory
. UTI: probably the most common cause of hematuria in adults
. Renal diseases: glomerulonephritis, radiation nephritis, radiation cystitis, pyelonephritis
. Endocarditis
4. Metabolic
. Calculus disease (85% of patients have hematuria)
. Hypercalciuria with microcalculi or nephrocalcinosis; most common cause of hematuria in children without UTI or glomerulonephritis
5. Congenital
. Cystic disease: polycystic kidney disease, solitary renal cyst
. Benign familial hematuria or thin basement membrane nephropathy
. Alport syndrome (hematuria, proteinuria, hearing loss)
. Renal tubular acidosis type 1, cystinuria, oxalosis
6. Hematologic
. Bleeding dyscrasias: e.g., hemophilia
. Henoch-Schonlein purpura
. Sickle-cell anemia
7. Vascular
. Hemangioma
. A-V malformations (rare)
. Nutcracker syndrome: Compression of left renal vein and subsequent renal parenchymal congestion
. Renal vein thrombosis
. Arterial emboli to kidney
8. Chemical
. Nephrotoxins: aminoglycosides, cyclosporine
9. Obstruction
. Hydronephrosis, from any cause
. BPH - rule out other causes of hematuria
10. Idiopathic
. Loin pain hematuria (most often young women on oral contraceptives)
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DIFFERENTIAL DIAGNOSIS
. Artifactual discoloration of the urine (pseudohematuria)
. Dehydration
. Dyes, e.g., phenazopyridine (Pyridium), rifampin, food colorings
. Precipitated urate crystals cause a pink or red urine color (e.g., in neonates)
. Vaginal bleeding (e.g., menses, dysfunctional uterine bleeding, vaginal trauma)
. Genital/perineal trauma
. Malingering/other secondary gain (urine obtained by catheterization will be helpful
. Urine dipstick
. False negatives: high-dose Vitamin C; low urine pH (<5)
. False positives: oxidizers (povidone, bacterial peroxidases, bleach), myoglobin
. Urinalysis; confi rm dipstick findings and quantify RBCs (normal urine contains . 5 RBCs/high power field on any single specimen and . 3 RBCs/high power fi eld on any 2 successive specimens on centrifuged specimens).
Red cell casts pathognomonic of glomerular bleeding. Proteinuria (large) suggests glomerular leak.
Dysmorphic RBCs most often from glomerular origin.
. Urine culture if pyuria is present
. Renal function tests: BUN and creatinine
. PT for patients on warfarin or suspected of abusing warfarin
. CBC may show elevated WBC, anemia unlikely from hematuria although gross hematuria can produce significant blood loss. Anemia and microscopic hematuria usually secondary to chronic disease
. Urine cytology, although atypical cells can be seen with benign conditions. Good for high grade transitional cell carcinoma
SPECIAL TESTS
. Renal biopsy may be necessary to diagnosis glomerulonephritis and with gross hematuria and crescentic nephritis, urgent immunosuppressive therapy may be needed
. Retrograde pyelogram can be considered in patients with documented allergy to IV contrast
. Sensitive for small lesions of supravesical collecting system
. Valuable for patients with allergy or contraindication to iodine contrast because contrast is not absorbed in this test
. Requires cystoscopy
. Cystoscopy
. Best for evaluation of bladder pathology especially small transitional carcinomas
. Flexible cystoscopy is less painful and may have increased sensitivity
. Ureteroscopy/pyeloscopy
. Best for visualization of suspected supravesical collecting system lesions
. Biopsy, excision, fulguration, or extraction of lesions/stones possible
. Requires anesthesia
. Requires cystoscopy
. Risk of injury to collecting system
IMAGING
. Intravenous pyelogram (IVP)
. Overall best study, widely available, cost effi cient
. Limited sensitivity for small renal masses, and differentiating cystic from solid masses
. Addition of tomography increases sensitivity
. Potential reactions to intravenous iodine contrast media (especially with dehydration, diabetic, on metformin, and in pre-existent renal insufficiency)
. Renal ultrasonography
. Best for differentiating cystic from solid masses and finding radiolucent stones
. Sensitive for hydronephrosis
. No radiation or iodinated contrast exposure
. Cost efficient
. Poor sensitivity for small renal masses
. CT
. Most sensitive for evaluating renal masses, and perirenal pathology
. Visualizes major renal vasculature
. Satisfactory for stone detection but can misinterpret non-urologic calcifi cations
. Visualization of ureters is discontinuous
. Less cost efficient
. Potential reactions to intravenous iodine contrast media identical to IVP
. Need for oral contrast media to opacify bowel
. MRI
. Similar to CT in sensitivity for renal masses
. No radiation exposure
. Least cost efficient
* RENAL ARTERIOGRAM IN CASE OF HYPERNEPHROMA
* ANTI GLOMERULAR BASEMENT MEMBRANE ANTIBODIES
* COMPLIMENT LEVELS
* HEPATITIS B & C SEROLOGY