Case Scenarios Of Patients presenting With Hematuria And Their Diagnosis .

A. Transitional cell carcinoma of the bladder
B. Renal stones
C. Chlamydia
D. IgA nephropathy
E. Urinary tract infection
F. Renal cell carcinoma
G. Polycystic kidney disease
H. Goodpasture's syndrome
I. Urethral syndrome
J. Renal vein thrombosis

For each one of the scenarios given below  please select the most likely diagnosis from the list of choices given above:

1. A 14-year-old boy develops visible haematuria following an upper respiratory tract infection.

Answer: IgA nephropathy which is also called Berger's disease.

2. A 60-year-old man presents with visible haematuria for the past three weeks. He has an ache in the left loin but examination is unremarkable other than a left varicocele. He also notes to feeling intermittently hot and sweaty.

Answer: Renal cell carcinoma.

Features of renal cell carcinoma include:

• classical triad: haematuria, loin pain, abdominal mass
• pyrexia of unknown origin
• left varicocele (due to occlusion of left testicular vein)
• endocrine effects: may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH
• 25% have metastases at presentation

3. A 21-year-old female complains of dysuria for the past week, despite just completing a three day course of trimethoprim. Urine dipstick is positive for blood + and leucocytes +. A MSSU shows no organism.

Answer: Chlamydia infection

Features of Chlamydia include: 

•  asymptomatic in around 70% of women and 50% of men
• women: cervicitis (discharge, bleeding), dysuria
• men: urethral discharge, dysuria

Brief Discussion On Hematuria 

The management of patients with haematuria is often difficult due to the absence of widely followed guidelines. It is sometimes unclear whether patients are best managed in primary care, by urologists or by nephrologists. 

The terminology surrounding haematuria is changing. 

Microscopic or dipstick positive haematuria is increasingly termed non-visible haematuria whilst macroscopic haematuria is termed visible haematuria. Non-visible haematuria is found in around 2.5% of the population. 

Causes of transient or spurious non-visible haematuria are: 

• urinary tract infection 
• menstruation 
• vigorous exercise (this normally settles after around 3 days) 
• sexual intercourse

Causes of persistent non-visible haematuria are:

• cancer (bladder, renal, prostate) 
• stones 
• benign prostatic hyperplasia 
• prostatitis 
• urethritis e.g. Chlamydia 
• renal causes: IgA nephropathy, thin basement membrane disease 

Spurious causes - red/orange urine, where blood is not present on dipstick:

• foods: beetroot, rhubarb 
• drugs: rifampicin, doxorubicin 

Management:  Current evidence does not support screening for haematuria. The incidence of non-visible haematuria is similar in patients taking aspirin/warfarin to the general population hence these patients should also be investigated.

• urine dipstick is the test of choice for detecting haematuria 
• persistent non-visible haematuria is often defined as blood being present in 2 out of 3 samples tested 2-3 weeks apart 
• renal function, albumin:creatinine (ACR) or protein:creatinine ratio (PCR) and blood pressure should also be checked.
• urine microscopy may be used but time to analysis significantly affects the number of red blood cells detected.

NICE urgent cancer referral guidelines include: 

• Patient of any age with painless macroscopic haematuria 
• patients under the age of 40 years with normal renal function, no proteinuria and who are normotensive do not need to be referred and may be managed in primary care 
• aged 40 years and older who present with recurrent or persistent urinary tract infection associated with haematuria 
• aged 50 years and older who are found to have unexplained microscopic haematuria