Hematuria Barbara Kahn MD Virginia Urology ICD10 codes

Hematuria Barbara Kahn, MD Virginia Urology

ICD-10 codes • R 31 Hematuria • R 31. 0 Gross hematuria • R 31. 1 Benign essential microscopic hematuria • R 31. 2 Other microscopic hematuria • R 31. 21 Asymptomatic microscopic hematuria • R 31. 29 Other microscopic hematuria • R 31. 9 Hematuria, unspecified • N 30. 01 acute cystitis with hematuria

Objectives • To define microscopic hematuria • To describe the evaluation and treatment of hematuria

Hematuria Classifications n. Microscopic hematuria n. Glomerular n. Non-Glomerular n. Macroscopic “Gross” hematuria n. Symptoms: pain, burning vs asymptomatic

DEFINITION Microscopic Hematuria 3 or more RBCs/hpf in urinary sediment from 1 properly collected UA *cannot be diagnosed by dipstick

Urine Dipstick n+ dipstick for hematuria = peroxidase reaction to hemoglobin n Hematuria or RBC’s n Myoglobinuria n Hemoglobinuria n. Microscopic evaluation is essential for distinguishing hematuria from myo-hemoglobinuria

Dipstick False Positives n. Menstrual blood – most common n Cath specimen n. Dehydration (increased specific gravity) n. Oxidizing agents (hypochlorite, povidone, bacterial peroxidases) n. Myoglobinuria/hemoglobinuria

Dipstick False Negatives n. Reducing agents (high dose Vitamin C) n. Low urine p. H (< 5. 1) n. Urine too dilute SG < 1. 007

Dipstick +, Micro • Repeat urine specimen 3 times • If any test has 3 or more RBC/hpf then work up • If all negative on micro, no further work up

Medical vs Surgical Hematuria n. Renal/Glomerular Hematuria Proteinuria Red cell casts Dysmorphic red blood cells Renal insuffficiency n. Non-glomerular Hematuria Circular red cells Absence of casts

Medical Renal Disease

Glomerular Hematuria

Hematuria Initial Evaluation n. History n. Physical Examination n. UA dipstick, microscopy n. Urine culture if possible infection ne. GFR, BUN, Cr

Important History Age Gender History of trauma Timing of blood in stream Associated symptoms Association with exercise Recent upper respiratory tract infection Medical, surgical, gynecological history Meds: anticoagulation Tobacco use Radiation exposure Family history Occupation

Cystoscopy • Should be performed in all patients with AMH age 35 years and older, and those younger than 35 with risk factors.

Risk Factors

Imaging n. CT urogram is gold standard n. MR urogram if renal insufficiency/severe contrast allergy/pregnant n. US or noncontrast CT with retrograde pyelograms if unable to get CTU or MRU

IV Contrast Allergy • May premedicate • Prednisolone 30 mg PO 12 hours and 2 hours prior • Initial dose must be >6 hours prior

Tumor Markers • Urine cytology, NMP 22, BTA-stat, Uro-vysion FISH • No longer routinely recommended

Risk of Disease in AMH n. GU malignancy 4%. (0 -9. 3%) n. Renal, upper tract urothelial, bladder n Stones >5% (1. 4 -25. 6%) n BPH >10% (1 -47%) n Urethral Stricture 2% (1 -7%) n. No pathology 37. 3 -80. 6% n. Risk of pathology higher with gross hematuria n 24% GU malignancy n 35% significant disease

Following a Negative Work up • Repeat annual microscopic urinalysis x 2 years • If negative – no further work up • If persistent – continue annual microscoic urinalysis AND repeat work up in 35 years • Neoplasms found in 9% with negative work-up but persistent microhematuria.

Association Between Use of Antithrombotic Medication and Hematuria-Related Complications. • More hematuria-related complications (ER visits, hospitalizations, urologic procedures) among patient exposed to antithrombotic agents than not exposed • 123. 95 events per 1000 person-years vs 80. 17 events per 1000 person-years • Patients exposed to antithrombotic agents were more likely to be diagnosed with bladder cancer within 6 months than those note exposed

Incidence of Visible Haematuria among Antithrombotic Agents: a Systematic Review of Over 175, 000 Patients. • Warfarin had the greatest risk of hematuria, but was less likely to cause major hematuria compared to novel antithrombotic agents • Urologic pathology identified in 44%, malignancy in 24%

References n. Diagnosis, evaluation, and follow up of asymptomatic microhematuria (AMH) in adults: AUA guideline, validated 2016 n. Jones, S and Rao. CCf Journal 2008. 75(3) 227 -233. How To Evaluate Dipstick Hematuria. What to Do Before You Refer. n. Jones, S and Rao. J Urology 2010. 183(2) 560 -565. Dipstick Pseudohematuria: Unneccessary Consultation and Evaluation. n. Bhatt, NR. et al. J Urology 2017. pii: S 0090 -4295(17)31220 -7. Incidence of Visible Haematuria among Antithrombotic Agents: a Systematic Review of Over 175, 000 Patients n. Wallis, CJD et al. JAMA 2017. Oct 3; 318(13): 1260 -1271. Association Between Use of Antithrombotic Medication and Hematuria-Related Complications.

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