Hematuria, gross

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Chapter 22 HEMATURIA, GROSS

Theodore X. O’Connell

General Discussion

Gross hematuria is defined as blood that can be seen with the naked eye. In one study, gross hematuria had an estimated incidence of 1.3 per 1000. In contrast to microscopic hematuria, systematic evaluation of gross hematuria often yields results, and most patients have a clinically important cause identified. The source of bleeding may originate from the glomerulus and interstitium, the urinary tract, or the renal vasculature.

Cola-colored urine, red blood cell (RBC) casts, and dysmorphic RBCs suggest glomerular bleeding. Edema, hypertension, and proteinuria are also suggestive of glomerulonephritis. Macroscopic hematuria from the bladder and urethra is usually pink or red. An absence of RBCs in the urine with a positive dipstick reaction suggests hemoglobinuria or myoglobinuria.

The approach to gross hematuria begins with a description of the urine and questions directed toward associated symptoms. Recent illnesses, medication use, and family history also may provide important clues to the diagnosis. Discussion of each of the causes of hematuria is beyond the scope of this chapter but can be found in Meyers.4

Asymptomatic gross hematuria presents more of a challenge. All patients with asymptomatic gross hematuria should first have radiologic interrogation to rule out renal and bladder tumors. IgA nephropathy commonly presents with recurrent episodes of painless, gross hematuria, with a mean age of presentation of 9 to 10 years in children. Acute postinfectious glomerulonephritis is the most common form of glomerulonephritis in children, and may be asymptomatic. Gross hematuria may occur after high intensity or long duration exercise.

An algorithm for the approach to gross hematuria is provided below, (Figure 22-1) in addition to selected tests that may be used in the evaluation.

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Figure 22-1 Macroscopic hematuria.

(From Meyers KEC. Evaluation of hematuria in children. Urol Clin North Am 2004;31:559–573, with permission.)