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Haematuria

Medicine > Infection

Differential Diagnosis Schema 🧠

Renal Causes

  • Glomerulonephritis: Presents with haematuria, proteinuria, and often hypertension; may have preceding infection (e.g., post-streptococcal).
  • Polycystic Kidney Disease: Often presents with visible haematuria, abdominal pain, and hypertension; may have a family history.
  • Renal Cell Carcinoma: Painless visible haematuria, often with flank pain and a palpable mass; may have systemic symptoms like weight loss or fever.
  • Interstitial Nephritis: Can present with haematuria, often drug-induced or associated with autoimmune conditions.
  • Papillary Necrosis: May be associated with analgesic overuse, diabetes, or sickle cell disease; presents with haematuria and flank pain.
  • Renal Trauma: Visible haematuria following abdominal or flank injury.
  • IgA Nephropathy: Recurrent episodes of haematuria, often following an upper respiratory tract infection.

Urological Causes

  • Bladder Cancer: Painless visible haematuria, more common in older adults and smokers.
  • Urinary Tract Infection (UTI): Presents with haematuria, dysuria, frequency, and urgency; often with suprapubic pain.
  • Urolithiasis (Kidney Stones): Visible or non-visible haematuria with severe flank pain radiating to the groin; may be associated with nausea and vomiting.
  • Benign Prostatic Hyperplasia (BPH): Non-visible or visible haematuria, often with lower urinary tract symptoms (LUTS) such as hesitancy, weak stream, and nocturia.
  • Prostate Cancer: Haematuria with LUTS; more common in older men, may have back pain or bone pain if metastatic.
  • Trauma: Visible haematuria following instrumentation, catheterisation, or blunt trauma.
  • Strenuous Exercise: Transient, non-visible haematuria, often resolves spontaneously; known as “jogger’s haematuria”.
  • Schistosomiasis: Consider in patients with travel history to endemic areas; presents with haematuria, especially terminal haematuria.
  • Radiation Cystitis: Haematuria following radiation therapy to the pelvis.

Systemic Causes

  • Coagulopathy: Haematuria due to bleeding disorders (e.g., haemophilia) or anticoagulant therapy.
  • Sickle Cell Disease: Can cause papillary necrosis and haematuria, often associated with pain crises.
  • Vasculitis: Systemic vasculitides like granulomatosis with polyangiitis (Wegener’s) can present with haematuria, often with renal involvement.
  • Malignant Hypertension: Severe hypertension can cause haematuria due to glomerular injury.
  • Thrombotic Microangiopathy: Conditions like thrombotic thrombocytopenic purpura (TTP) can cause haematuria due to microvascular injury.
  • Lupus Nephritis: Autoimmune condition causing glomerulonephritis, leading to haematuria, proteinuria, and renal impairment.
  • Alport Syndrome: Genetic disorder causing glomerular basement membrane abnormalities, often presents with haematuria and progressive renal failure.
  • Endocarditis: Can cause haematuria due to immune complex deposition in the kidneys.
  • Drugs: Certain drugs, such as cyclophosphamide, can cause haemorrhagic cystitis and haematuria.

Key Points in History 🥼

Symptom Onset and Characteristics

  • Onset: Sudden onset may suggest stones, trauma, or UTI; gradual onset could indicate malignancy.
  • Visible vs. Non-Visible: Visible haematuria is more concerning for malignancy or significant renal pathology.
  • Pain: Painful haematuria is often associated with UTI, stones, or trauma; painless haematuria is concerning for malignancy.
  • Associated LUTS: Symptoms such as frequency, urgency, or dysuria suggest a lower urinary tract source like UTI or BPH.
  • Fever or Rigors: Suggests an infectious cause, particularly pyelonephritis or urosepsis.
  • Haemoptysis, Skin Rash, Joint Pain: These associated symptoms might suggest a systemic cause such as vasculitis or lupus.
  • Timing of Haematuria: Initial haematuria suggests urethral pathology, terminal haematuria suggests bladder or prostate involvement, and total haematuria suggests a renal or ureteric source.
  • Clots: The presence of clots can suggest a significant source of bleeding, often from the bladder or upper urinary tract.

Background

  • Past Medical History: Conditions such as recurrent UTIs, nephrolithiasis, known malignancy, or systemic diseases like diabetes should be noted.
  • Drug History: Review anticoagulant use, NSAIDs, and any recent use of nephrotoxic drugs.
  • Family History: Consider family history of renal disease, polycystic kidney disease, or hereditary malignancies.
  • Travel History: Important for assessing risk of schistosomiasis or other endemic diseases.
  • Social History: Smoking (increased risk of bladder cancer), alcohol use, and occupational exposures to chemicals or dyes.
  • Recent Procedures: Recent instrumentation, catheterisation, or surgery may cause trauma leading to haematuria.
  • Menstrual History: In women, ensure that haematuria is not due to contamination from menstrual blood.
  • Trauma History: Any history of recent trauma to the abdomen or back that might suggest renal injury.
  • Dietary History: High intake of oxalate-rich foods or dehydration can predispose to stone formation.

Possible Investigations 🌡️

Urine Analysis

  • Urine Dipstick: Initial test to confirm haematuria and assess for proteinuria, nitrites, and leukocytes suggestive of infection.
  • Urine Microscopy: To identify red blood cells, white blood cells, casts, and crystals; helps differentiate between glomerular and non-glomerular causes.
  • Urine Culture: Indicated if UTI is suspected, especially with associated symptoms like dysuria or frequency.
  • Urine Cytology: To detect malignant cells, particularly in cases of visible haematuria with a high suspicion of bladder cancer.
  • Urine Protein-to-Creatinine Ratio: To assess the degree of proteinuria, which may suggest glomerular disease.
  • 24-Hour Urine Collection: May be useful in cases of recurrent or unexplained haematuria to assess for proteinuria, calcium, and oxalate excretion.

Blood Tests

  • Full Blood Count (FBC): To assess for anaemia, leukocytosis, and thrombocytopenia; may indicate bleeding, infection, or marrow involvement.
  • Urea and Electrolytes (U&E): To assess renal function and electrolyte balance, especially in suspected renal disease or dehydration.
  • Clotting Screen: To assess for coagulopathy, particularly in patients on anticoagulants or with a history of bleeding disorders.
  • Creatinine and eGFR: To assess renal function, particularly if glomerulonephritis or acute kidney injury is suspected.
  • ESR/CRP: Inflammatory markers that may be elevated in vasculitis, infection, or malignancy.
  • Autoimmune Screen: ANA, ANCA, and complement levels may be indicated if vasculitis or lupus nephritis is suspected.
  • PSA: Prostate-specific antigen test in older men with LUTS or suspicion of prostate cancer.
  • Blood Cultures: Indicated if there is a suspicion of systemic infection or endocarditis.
  • Liver Function Tests: To assess for liver disease, particularly if there is a suspicion of coagulopathy.
  • Sickle Cell Screen: In patients of appropriate ethnicity or with a family history, to rule out sickle cell disease.

Imaging and Special Tests

  • Renal Ultrasound: First-line imaging to assess for renal masses, hydronephrosis, and stones.
  • CT Urogram: Gold standard for investigating haematuria, particularly in assessing the upper urinary tract for stones, tumours, and anatomical abnormalities.
  • Cystoscopy: Essential for visualising the bladder and urethra, particularly if bladder cancer or other lower urinary tract pathology is suspected.
  • Intravenous Pyelogram (IVP): Used less commonly now due to advances in CT imaging, but may still be used in some settings.
  • MRI Abdomen/Pelvis: Considered in complex cases or when there is a need to avoid ionising radiation, such as in young patients or pregnancy.
  • Renal Biopsy: Indicated in cases of suspected glomerulonephritis or unexplained renal impairment with haematuria.
  • Urine Bence-Jones Protein: To assess for multiple myeloma in patients with suspected plasma cell disorders.
  • VCUG (Voiding Cystourethrogram): Useful in children with recurrent UTIs to assess for vesicoureteral reflux.

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Infection