haematuria

aetiology by site

primary glomerular disease
multisystem disease:
- SLE, HSP, HUS, PAN, Wegener's granulomatosis, Goodpasture's syndrome

blood noted only on initiation suggests urethral cause
blood seen mainly on last few drops suggests prostatic or bladder neck source (including blood clots pooling at base of bladder)
- may occur after injury or straining
haematuria throughout urination suggests source in bladder, ureter or kidney
brown or smoky-colored urine usually has a renal source
blood clots indicate non-glomerular renal or lower urinary tract source
if cyclic with menses, may be due to endometriosis of ureter or bladder

flank pain suggests calculus, neoplasm, renal infarction, obstruction or infection as a cause
symptoms of dysuria, frequency or suprapubic pain suggests cystitis or urethritis
in adult men, perineal pain, dysuria and terminal haematuria suggests prostatitis
recent sore throat suggests possibility of post-streptococcal GN
foreign travel or residence suggests schistosomiasis or TB
drugs may cause acute interstitial nephritis, papillary necrosis, or haemorrhagic cystitis
FH of HbS, polycystic or other kidney disease or renal calculi
15-20% of individuals exhibit haematuria after strenuous exercise which resolves in a few days

arthritis, skin lesions, HT or oedema suggest GN
new heart murmur (endocarditis) or AF suggests renal embolism
costovertebral angle tenderness suggests pyelonephritis, stone disease
enlarged kidney suggests polycystic kidney or malignancy
prostatic examination may offer clues to presence of prostatitis, BPH or malignancy
ext. genitalia may reveal urethral meatal lesion
PV exam to exclude vulvovaginal causes of bleeding
urinalysis with m/c/s if ? infective
pathology tests - urea and creatinine
if suspect calculi, polycystic kidney, tumour or obstruction then IVP or if C/I then US
if active gross haematuria or no upper lesion then consider cystoscopy
if elderly pt and other features are unhelpful then consider urinary cytology
if asymptomatic, with no other abnormality on urinalysis, and not azotaemic, hypertensive, or severely anaemic, & who have no evidence of intrinsic renal disease, may be followed up as outpatients (?except if known bleeding disorder), others should generally be admitted for prompt evaluation.
extensive OP evaluation is usually not undertaken for pts < 40 yrs with isolated episode of haematuria, but most patients over 40yrs should have a thorough evaluation