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Hematuria

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Evaluation of nonglomerular hematuria

Test Advantages Disadvantages

Intravenous pyelogram Excellent visualization of May miss bladder lesions; the kidney, collecting system nephrotoxicity and ureter Cystoscopy Best way to examine the Invasive, uncomfortable and expen bladder sive Ultrasound If of good quality, as sensitive as Less sensitive than IVP for ureter IVP for renal lesions, with less and bladder morbidity and cost Retrograde The best test for examine the Invasive, not useful for examining pyelography ureters can be combined other parts of the urinary with cystoscopy collecting system

Urinary Sensitivity 67 percent, Useful only for cancer, mainly of cytology specificity 96 percent for thebladder uroepithelial cancer CT scan Excellent for examining the Expensive renal parenchyma Angiography Useful for gross hematuria when Invasive, expensive other tests have not revealed the cause, the only good test for renal Cared cells per high powered field on at least 1 of 3 screening urinalyses is associated with an increased incidence of malignancy (bladder, kidney, or prostate). Tumors are more common in men especially over the age of 50.

Work up of nonglomerular hematuria

Once glomerular bleeding has been excluded, the diagnostic work-up should include a search for mass lesions in the kidney, collecting system, ureters, and bladder. The diagnostic yield in adults increases with age and is higher for gross hematuria (5 to 23 percent) than for microscopic hematuria (up to 14 percent), and for higher grades of bleeding than for lesser grades.
An intravenous pyelogram (IVP) or a renal ultrasound, looking for calculi, a renal mass, or polycystic kidney disease is the initial test in most patients. An IVP may be a reasonable first choice in young patients, since it can detect lesions such as medullary sponge kidney that may not be seen by ultrasonography. In patients who have a contraindication to IVP (eg, dye allergy), ultrasound may be used instead; this test is safer and less expensive, but has a somewhat lower diagnostic yield.

Young patients with a normal IVP do not need ultrasonography, since the yield of significant findings is very low in this setting. Older patients, however, may be best managed with initial ultrasonography, which is better at visualizing small renal tumors. Performance of CT scan or MR imaging is not usually required as part of the initial evaluation.

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