Cause Of Microscopic Haematuria Research Articles

An evidence-based microscopic hematuria care pathway optimizes decision-making among providers.

Microscopic hematuria (MH) has many etiologies in women and requires specific gynecologic evaluation. We created a standardized MH pathway to serve as an evidence-based decision aid for providers in our practice. Using a modified Delphi process, a multidisciplinary team reviewed existing guidelines for MH diagnosis and treatment to reach consensus on care pathway components. Entry into the care pathway by an advanced practice provider is determined by the finding of ≥3 red blood cells per high-power field (RBC/HPF) on microscopic urinalysis. Initial evaluation includes history and physical exam. If there are signs of a gynecologic cause of MH, the conditions are treated and repeat urinalysis is performed in 6 months. If repeat urinalysis shows persistent MH or there are no other apparent causes for MH, we proceed with risk stratification. Through shared decision-making, low-risk patients may undergo repeat urinalysis in 6 months or cystoscopy with urinary tract ultrasound. For intermediate-risk patients, cystoscopy and urinary tract ultrasound are recommended. For high-risk patients, cystoscopy and axial upper urinary tract imaging are recommended. If evaluation is positive, urology referral is provided. If evaluation is negative, low-risk patients are released from care, but intermediate-risk or high-risk patients undergo repeat urinalysis in 12 months. If repeat urinalysis is positive, shared decision-making is used to determine a plan. We developed an MH care pathway to standardize care of women with MH across a multidisciplinary group. This pathway serves as a component of value-based care and supports evidence-based care by providers.

Pelvic examination: an iatrogenic cause of microscopic hematuria in women?

Microscopic hematuria (MH) in women is a common incidental finding that can trigger morbid and costly investigation. Identifying non-pathologic etiologies of MH may help limit unnecessary investigation. Our study aimed to determine whether pelvic examination (PE) increases the prevalence of MH in women. Between May 2018 and October 2018, 157 women > 18years of age and presenting to the Obstetrics and Gynecology private clinics at a tertiary care center were approached and asked to provide two urine samples: one before PE and one after. Samples were then analyzed to asses for the presence of MH. The McNemar test was used to evaluate whether the conversion from no MH to MH could be attributed to PE rather than to chance. An associated p < 0.05 was determined to be significant. Chi-square test was used to determine whether this conversion is influenced by age and menopausal status. Thirteen women (8.3%) had MH before PE. Of 144 participants with no initial MH, 22 (15.3%) had MH after PE. PE was significantly correlated with the conversion from no MH to MH (p = 0.002). The conversion from no MH to MH following PE was not correlated with age (p = 0.451) or menopausal status (p = 0.411). PE performed within an hour before urinalysis was found to be a risk factor for MH in women.

Microscopic Hematuria as a Screening Tool for Urologic Malignancies in Women.

Most causes of microscopic hematuria (MH) are benign but may indicate an underlying malignancy. Current MH evaluation guidelines are reflective of male urologic malignancy risks. The objective of this systematic review was to evaluate whether the finding of MH predicts subsequent urologic malignancy in women. MEDLINE was searched between January 1990 and June 8, 2018. The positive predictive value (PPV) of MH as a screening tool for urologic malignancy was calculated for each study individually and collectively. The pooled relative risk of urologic malignancy associated with MH was calculated. Seventeen studies were included. Eight studies included only women. In total, 300 urinary tract cancers were identified in 110,179 women with MH. The PPV of MH as a screening tool for cancer ranged from approximately 0.6% to 2.8%; confidence intervals (CIs) suggested this is a relatively unstable performance indicator because of small sample sizes. Average PPV across all studies was 2.13%, but the weighted average PPV was 0.24%. The risk of urologic malignancies among women with relative those without MH was 2.01 (95% CI, 1.61-2.51). Based on these limited data, we estimate that 859 (95% CI, 654-1250) women with MH would require complete evaluation to identify 1 urinary tract malignancy. A very small proportion of women with MH are likely to have a urologic malignancy. Approximately 859 women require full screening to identify 1 malignancy. Current evidence is limited, and further studies, specifically in women, are needed.

Multi-Detector Row Computed Tomography Urography (MDCTU) in the Evaluation of Microscopic Hematuria in Adults

Multi-detector row computed tomography urography (MDCTU) becomes the imaging modality of choice for evaluation of the kidneys and urinary tract. The aim of this study was to discuss and illustrate the role of MDCTU, on a 32-row CT scanner in the evaluation a variety of entities that were frequently associated with microscopic hematuria in adults. This prospective cohort study was performed in the period of August 2013 to October 2014. Fifty positive participants to microscopic hematuria were examined at the radiology department of Alnilin Diagnostic Medical Center and Antalya Medical Center. Computed tomography urography (CTU) scanning was performed using two powerful performances, high speed multi-detector row on 32-row CT scanners (Siemens Healthcare Global, Somatom Emotion Duo Eco). Statistical analysis was done through the standard Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, USA) version 15 for windows. MDCTU established the correct cause of microscopic hematuria in (44; 88%) of participants. In (6; 12%) of participants, no cause of hematuria was identified based on the standard of references. The causes of hematuria in (41; 82%) participants were diseases in the upper urinary tract, while urinary bladder neoplasms (2; 4%) and diverticulum (1; 2%) were the causes of hematuria (3; 6%) in the lower urinary tract. Thirty two-row MDCTU scanner demonstrated satisfactory results in the investigation of microscopic hematuria, being able to demonstrate a wide spectrum of diseases affecting the urinary tract is the main advantage of the technique.

Beta-Thalassemia Minor Is Associated with IgA Nephropathy

Jung Hyun Kang, M.D., Bo Rha Park, M.D., Kyung Soo Kim, M.D., Do Yeun Kim, M.D., Hee Jin Huh, M.D., Seok Lae Chae, M.D., and Sung Joon Shin, M.D.. Ann Lab Med 2013;33:153-5. https://doi.org/10.3343/alm.2013.33.2.153

Effect of Immobilization on Emerging of Hypercalciuria in Patients Admitted to Pediatric Intensive Care Unit

Purpose: Hypercalciuria as a common phenomenon in the normal population is associated with several complications such as urinary tract infections, colic pains and stone formation. In this study, our aim was to investigate association of immobilization and the incidence of hypercalciuria among children. Methods: Forty seven children who were active before the study over 2 years were hospitalized and immobilized in intensive care unit of hospital based on type or severity of illness. Calcium/ creatinine ratio was evaluated, the rate of over 0.21 was considered as hypercalciuria. In 40 healthy children, this value was determined and compared by statistical methods of Paired t-test and independent t –test. P values less than 0.05 was considered as statistically significant. Results: The prevalence of hypercalciuria in immobilized patients was significantly higher than that of the control group after 7 days, which was 37% versus 10% respectively. The rate rose from 37% to 53%, which was not statistically significant. Immobilization alone in the inception of hospitalization (first 48 hours) was associated with impaired calcium excretion in the urine. Urinary tract infection as a complication of hypercalciuria in patients and controls group such as hypercalciuria and uncommon calcium excretion was not normal, but microscopic hematuria was observed in patients with hypercalciuria in about 2.1 items. Conclusion: The hypercalciuria in the immobilized children was significantly more than in the normal children. One of the most common causes of microscopic hematuria in the immobilized patients was hypercalciuria.

Role of Sexual Intercourse in Hematuria and Proteinuria in Males and Females

Objective: A probable association has been proposed between sexual intercourse and hematuria and proteinuria in either sex. The present study was to assess the role of sexual intercourse in hematuria and proteinuria in immediate dipstick urine test and morning urine sample analysis and whether sexual intercourse might be a cause of microscopic hematuria and proteinuria. Material and Methods: Forty-two healthy married adult volunteers (27 male and 15 female; age range 20–48) were enrolled in a prospective clinical trial. Immediately after sexual intercourse urine samples were analyzed regarding hematuria and proteinuria with a dipstick, and the next morning samples for standard urinalysis. For categorical data analysis Fisher’s exact test was utilized. p < 0.05 was considered significant. Results: Proteinuria immediately after intercourse was significantly higher in males (88.9 vs. 13.3%, p < 0.001) but females showed significant higher hematuria (73.3 vs. 22.2%). None of the women developed hematuria and/or proteinuria in morning after urinalysis samples but males indicated significant proteinuria (33.3 vs. 0%, p = 0.02). Conclusions: Proteinuria and hematuria following sexual intercourse are gender-dependent, and temporally related to the timing of the testing and sexual activity. Testing the urine in the morning following intercourse may give false-positive protein results in men, but there is no evidence of false-positive hematuria in women unless the activity immediately precedes the testing.

ASYMPTOMATIC MICROHEMATURIA: AN INDICATION OF HEREDITARY HEMORRHAGIC TELANGIECTASIA?

Hereditary hemorrhagic telangiectasia (HHT) is a genetic angiodysplasia affecting multiple organs. Clinical manifestations include spontaneous and recurrent epistaxis, mucocutaneous telangiectases that bleed easily and arteriovenous malformations in many organs. Despite the anecdotal recommendations of some groups, to our knowledge information regarding the prevalence of microscopic hematuria (MH) in patients with HHT has not been reported to date. We evaluated the prevalence of MH in patients with HHT. Between January 2002 and June 2003, 116 consecutive patients with HHT were studied, of whom 20 were excluded because of a possible false-positive MH bias. Therefore, 53 males and 43 females with a mean age +/- SD of 45.8 +/- 15.8 years who had HHT underwent urine dipstick testing for heme and microscopic urinary examination. A control group of 192 males and 148 females with a mean age of 46.5 +/- 14.2 years and no statistical age or sex differences without HHT who were hospitalized in the same period at the same medical unit for gastrointestinal disorders was compared to the HHT cohort. MH was detected in 45 of 96 patients with HHT (47%) compared to 41 of 340 controls (12%) (p <0.0005). None of the patients with HHT showed abnormal renal function, proteinuria, hypercalciuria or hyperuricosuria. MH was due to glomerular hematuria in 29 of 45 patients (65%), postglomerular hematuria in 13 (29%) and mixed hematuria in 3 (6%). No gross hematuria was detected. Our results show that MH is common in patients with HHT. This might indicate the possibility of weak urinary tract bleeding due to telangiectases and/or small arteriovenous fistulas, which are typical HHT lesions. Therefore, HHT should be considered among the causes of MH. Urinalysis should always be performed when there is severe anemia in HHT patients with HHT, particularly those without other apparent bleeding sites.

Multiphasic Helical Computerized Tomography for the Assessment of Microscopic Hematuria:: A Prospective Study

We evaluated multiphasic helical computed tomography for the detection and characterization of lesions responsible for hematuria not diagnosed on prior urological surveillance studies. A total of 393 men and 207 women with recurrent microscopic hematuria but negative urological surveillance studies were examined at 4 participating institutions by multiphasic helical computerized tomography, consisting of pre-enhancement, arterial corticomedullary, parenchymal and excretory phase sequences generating 2 to 5 mm slices through the kidney and lower pelvis. The cause of microscopic hematuria was established in 256 of 600 patients with prior negative urological surveillance examinations with 0.91 sensitivity and 0.94 specificity. The diagnosis was correct in all subsequently proven cases of calculous and renal vascular disease. A total of 67 of 70 inflammatory kidney lesions, 24 of 25 renal neoplasms, 15 of 16 bladder neoplasms, 27 of 35 inflammatory bladder conditions and 21 of 23 ureteral lesions were also correctly diagnosed. The diagnosis of renal medullary and papillary necrosis, and neoplastic lesions of the kidney and bladder allowed the early institution of medical therapy or appropriate surgery. Multiphasic helical computerized tomography diagnosed lesions responsible for microhematuria in 42.6% of 600 patients with negative urological surveillance examinations. This relatively low cost and low co-morbidity examination is advocated for patients with negative urological surveillance examinations or even as a first examination.

Is sexual intercourse a significant cause of haematuria?

To determine whether recent sexual intercourse might be a cause of microscopic haematuria in patients referred to a urological unit following dipstick detection of urinary haemoglobin. Forty-eight volunteers (24 men and 24 women) consented to have heterosexual intercourse with their regular partner, and to provide samples of urine for testing before and from the first void on the morning after intercourse. After appropriate instruction, volunteers tested their own urine for the presence of blood using standard dipsticks. Any volunteer with haematuria either before or after intercourse was offered a standard haematuria assessment. The results were analysed using the chi-squared test. None of the volunteers tested positively for haematuria immediately before sexual intercourse; six of the 24 women (25%), but no men, became positive after intercourse (P < 0.01). Only one of the six women accepted the offer of a haematuria evaluation and no pathology was identified. These results suggest that up to a quarter of women develop microscopic haematuria as a direct result of sexual intercourse. A history of recent sexual intercourse should therefore be considered when assessing the clinical significance of microscopic haematuria in women.

Isolated microscopic haematuria in the genitourinary clinic: the value of renal biopsy.

Isolated microscopic haematuria is a common finding in the genitourinary clinic. The conventional approach to investigation includes urological referral for cystourethroscopy if renal imaging is normal. However the diagnostic yield is very low; in particular urothelial malignancy at age < 40 years is rare. Glomerular disease is increasingly recognized as a common cause of microscopic haematuria. In this study 50 patients with persistent microscopic haematuria detected at a genitourinary clinic underwent renal biopsy. Twelve (24%) had an abnormal biopsy--IgA nephropathy 6 (12%), thin membrane nephropathy 3 (6%), other glomerulonephritis 3 (6%). In 7 others no abnormality was found but information was incomplete as electron microscopy was unavailable. It is important to establish these diagnoses since some patients will develop progressive renal disease. In this clinical setting renal biopsy will give diagnostic and prognostic information, protects from repeated urological investigation, and allows reassurance if renal histology is normal. Renal biopsy is recommended for patients age < 40 years with persistent microscopic haematuria. An algorithm for the investigation of microscopic haematuria is presented.

Glomerular basement membrane thickness--a comparison of two methods of measurement in patients with unexplained haematuria

Thin glomerular basement membranes may be an important cause of microscopic haematuria. Unfortunately measurements are often not made because of the complicated methods currently employed. A simplified method of measurement of glomerular basement membrane thickness, involving only 16 selected measurements on a single glomerulus, was compared with the accepted, but time-consuming, orthogonal intercept technique. Thirty-one needle biopsies from patients with renal haematuria unexplained by conventional histology and immunofluorescence were studied. Measurements were made on the same ultrathin sections. The new method was found to give much lower values (mean (SD) 202+/-51 versus 282+/-52 nm) with limits of agreement of -131 to -30 nm compared with the orthogonal intercept method. The coefficient of repeatability was 39 nm for the orthogonal intercept method and 56 nm for the new method. However, using two glomeruli the new method had limits of agreement of -120 to -41 nm with a coefficient of repeatability of 38 nm. Provided two glomeruli are measured the new technique is sufficiently accurate for the diagnosis of thin membrane nephrology, in appropriate cases, and is much simpler and cheaper than the orthogonal intercept method.

The Significance of Hematuria in the Anticoagulated Patient

There have been many case reports of substantial renal disease in association with anticoagulation, yet the intensity of anticoagulation has changed over the years. In 1986, the American College of Chest Physicians and the Heart, Lung, and Blood Institute recommended a decrease in anticoagulation intensity. In addition, a variety of new methods to investigate hematuria have evolved, including computed tomography and red blood cell morphologic analysis. Because of these developments, we initiated a prospective study to evaluate the relationship between anticoagulation, microscopic hematuria, and major genitourinary tract disease. To determine the incidence, prevalence, and cause of microscopic hematuria, patients receiving long-term anticoagulation therapy and controls not receiving such therapy were monitored with monthly urinalyses in a 2-year prospective study. Patients who developed hematuria were further studied for genitourinary tract disease. The incidence of hematuria was analyzed with regard to relative levels of anticoagulation. The incidence of hematuria in the anticoagulated and control groups was 0.05 and 0.08 per 100 patient-months, respectively. The prevalence of hematuria was 3.2% in the anticoagulated group and 4.8% in the control group. Genitourinary tract disease was identified in 81% of patients with more than one episode of microscopic hematuria, and the cause of hematuria did not vary between groups. There was no correlation between the level of anticoagulation and the incidence of hematuria. Anticoagulation at currently recommended levels does not predispose patients to hematuria. Identifiable genitourinary tract disease is present in the majority of anticoagulated patients with microscopic hematuria.

Air-Exposed Urine Dipsticks Give False-Positive Results for Glucose and False-Negative Results for Blood

Urine dipstick jars often are left uncapped, which led the authors to wonder what effect prolonged air exposure might have on dipstick accuracy. Unexpired Ames Multistixs (Miles Inc., Elkhart, IN) were exposed to ambient air for intervals of up to eight weeks and were used to test urine for the presence or absence of blood, protein, and glucose. Multistixs were read by a blinded participant. A urine sample reading negative for glucose with unexposed (control) Multistixs tested trace positive with three of three Multistixs exposed for 7 days, and 1+ (three of six) or trace positive (three of six) (P less than 0.05) with Multistixs exposed for 28 days. A urine sample reading 1+ for blood with controls tested negative with five of six (P less than 0.05) and six of six (P less than 0.05) Multistixs exposed for 28 and 56 days, respectively. Protein detection was accurate up to 56 days. The authors conclude that urine dipstick jars should be recapped to avoid prompting needless evaluations of glucosuria or delaying detection of important causes of microscopic hematuria.

Hypercalciuria as a cause of persistent or recurrent haematuria.

Of 91 children with idiopathic persistent or recurrent haematuria, eight also had hypercalciuria. This was transient in three and persistent in five. Persistent hypercalciuria was a rare cause of microscopic haematuria (two of 80), but common in association with gross haematuria (three of 11).