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Hematuria
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Hematuria is the presence of blood, specifically red blood
cells, in the urine. Whether the blood is visible only under a
microscope or visible to the naked eye, hematuria is a sign
that something is causing bleeding in the genitourinary tract:
the kidneys, the tubes that carry urine from the kidneys to
the bladder (ureters), the prostate gland (in men), the
bladder, or the tube that carries urine from the bladder out
of the body (urethra).
Bleeding may happen once or it may be recurrent. It can
indicate different problems in men and women. Causes of this
condition range from non–life threatening (e.g., urinary tract
infection) to serious (e.g., cancer, kidney disease).
Therefore, a physician should be consulted as soon as
possible.
Types
There are two types of hematuria, microscopic and gross (or
macroscopic). In microscopic hematuria, the amount of blood in
the urine is so small that it can be seen only under a
microscope. A small number of people experience microscopic
hematuria that has no discernible cause (idiopathic hematuria).
These people normally excrete a higher number of red blood
cells.
In gross hematuria the urine is pink, red, or dark
brown and may contain small blood clots. The amount of blood
in the urine does not necessarily indicate the seriousness of
the underlying problem. As little as 1 milliliter (0.03
ounces) of blood will turn the urine red.
"Joggers hematuria" results from repeated jarring of
the bladder during jogging or long-distance running.
Reddish urine that is not caused by blood in the urine is
called pseudohematuria. Excessive consumption of beets,
berries, or rhubarb; food coloring; and certain laxatives and
pain medications can produce pink or reddish urine.
Incidence
Hematuria occurs in up to 10% of the general population.
Causes
Many conditions are associated with hematuria. The most common
causes include the following:
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Benign
prostatic hyperplasia (BPH) in men over 40
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Kidney and
bladder stones
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Kidney
disease
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Medications
(e.g., quinine, rifampin, phenytoin)
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Trauma (e.g.,
a blow to the kidneys)
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Tumors and/or
cancer in the urinary system
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Urinary tract
blockages
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Viral
infections of the urinary tract and sexually transmitted
diseases,
particularly in women
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There are rare diseases and genetic
disorders that also cause hematuria. Some of these are:
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Sickle cell
anemia (inherited blood disorder)
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Systemic
lupus erythmatosus (chronic inflammatory disorder of
connective tissue)
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von Hippel-Landau
disease (hereditary disease in which benign tumors form on
the spinal cord, kidneys, testicles, and other organs)
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Signs and Symptoms
In many cases, blood in the urine (gross or microscopic) is
the only sign of a disorder. In others, a variety of symptoms,
such as the following, may be present.
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Abdominal
pain
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Decreased
urinary force, hesitance, incomplete voiding
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Fever
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Frequent
urination (polyuria)
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Pain during
urination (dysuria)
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Pain in the
flank or side
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Urinary
urgency
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Diagnosis
Classification
Bleeding is classified by when it occurs during urination,
which may indicate the location of the problem.
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Onset of
urination (initial hematuria)—urethra or prostate (men)
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Throughout
urination (total hematuria)—bladder, ureter, or kidneys
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End of
urination (terminal hematuria)—bladder or prostate (men)
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Symptoms may indicate the site and/or cause
of bleeding:
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Abdominal
pain—inflammation of the kidney or ureter caused by
trauma, infection, or tumor
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Decreased
urinary force, hesitance, or incomplete voiding—lower
urinary tract, benign prostate hyperplasia, tumor
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Fever—infection, typically of the kidney or ureter
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Pain in the
flank—kidney trauma or tumor
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Urinary
urgency, pain, or frequency—bladder cancer
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The physician takes a complete personal and
family medical history. The personal history can provide
useful information:
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Drinking and
smoking
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Exposure to
toxic substance dating back 25 years or more
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History of
kidney stones
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Injuries and
infections
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Recent and
past drug use
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Recent
illness
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Urinary
habits
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The family history may reveal inherited
predispositions to kidney stone disease, sickle cell anemia,
von Hippel-Lindau disease, or another genetic disorder
associated with hematuria.
A thorough physical examination is performed, with emphasis on
the urinary tract, abdomen, pelvis, genitals, and rectum.
Tests
In cases of suspected microscopic hematuria, a sample of the
patient's midstream urine is applied to a chemically treated
strip. The chemical changes color if blood is in the urine.
The intensity of the color indicates the amount of blood
present. This test (called a dipstick test) is performed in
the doctor's office.
A positive result warrants examination of the urine under the
microscope to look for the presence of cancer cells (urine
cytology). A urine culture may be grown to check for various
infections. The tests may be repeated on a 24-hour collection
of the patient's urine, and a blood chemistry workup may be
ordered.
Cystourethroscopy, or cystoscopy, is performed when the
cause of gross or microscopic hematuria cannot be identified.
Local anesthesia is given, and a small, rigid or flexible
fiber-optic instrument is inserted into the urethra. The
physician can visually inspect the urethra, bladder, and
prostate through the cystoscope. The procedure takes about 10
minutes. Some patients experience minor short-term discomfort
with urination or slight spotting of blood over the next
couple of days.
Intravenous pyelogram (IVP) is a special x-ray
procedure in which a colorless dye containing iodine is
injected into a vein in the patient's arm. The dye collects in
the urinary system and provides enhanced contrast for a series
of x-rays taken over 30 minutes. This produces a better image
of the kidneys, ureters, and bladder and can reveal stones,
tumors, blockages, and other possible causes of hematuria.
After the procedure, the patient may be asked to go to the
bathroom, completely empty their bladder, and return for a
final x-ray.
Patients who previously had an allergic reaction to
intravenous dye or to shellfish should tell their doctor
before undergoing an IVP.
If these tests fail to show the cause of hematuria, ultrasound
or computer-assisted tomography (CAT scan) may be ordered.
Differential Diagnosis
When no specific cause can be found, bladder and kidney
stones, cancer, and other life-threatening diseases can be
ruled out. The possible causes that remain include conditions
that may correct themselves, or the hematuria may be
idiopathic. Men over the age of 50 with no clear diagnosis
should have a yearly prostate specific antigen (PSA) test to
screen for prostate cancer.
Treatment
Treatment ranges from antibiotic therapy to
surgery, depending on the underlying cause.
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Benign
prostatic hyperplasia (BPH) may be treated many ways.
Eliminating foods and beverages from the diet and
over-the-counter medications that irritate the prostate
and cause it to swell is one option. Medication (e.g.,
terazosin) is often prescribed to treat BPH. When the
condition does not respond to these measures, surgical
removal of all or part of the gland may be recommended.
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Kidney and
bladder stones typically require procedures that remove or
break up the stones, as well as measures to prevent their
recurrence.
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Kidney
disease is treated according to diagnosis. In severe
cases, dialysis may be necessary.
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Medications
(e.g., quinine, rifampin, phenytoin) that cause hematuria
are discontinued.
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Trauma-induced hematuria (e.g., a blow to the kidneys) is
treated according to the severity of the injury, ranging
from bed rest and close clinical observation to surgical
repair or, in extreme cases, removal of the damaged tissue
or organ.
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Cancerous
tumors found in the kidney, ureters, prostate, or bladder
may be treated with radiotherapy, chemotherapy, and
surgery.
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Urinary tract
blockages are treated with correction or removal of the
blockage.
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Viral
infections of the urinary tract and sexually transmitted
diseases, particularly in women, are treated with
medication.
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Prognosis
Prognosis differs according to the underlying condition and
the patient's response to treatment.
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