The essential problem is to discover the cause of the bleeding. In addition to the clinical examination and cytobacteriological urinalysis (urine culture), what are the initial radiological examinations?
Intravenous urography remains an excellent exploration: well standardized, with documents easy to communicate, especially while exploring the excretory system, including the ureters. The main drawback is the lack of sensitivity to detect small renal masses and analysis. The combination in the same examination of CT and intravenous urography (IVU) overcomes this drawback. Ultrasound of the kidneys and urinary tract (bladder) is not enough because it infringes the lesions of the ureters.
It may be associated with IVU.
The main causes are young patients, the infection of the lower urinary tract stones and, in older subjects, prostate diseases (bacterial prostatitis, adenoma, carcinoma), tumors of the urinary tract, kidney carcinomas. Papillary necrosis (in diabetes mellitus or sickle cell disease), tuberculosis and urinary schistosomiasis, renal angiomyolipoma (with or without tuberous sclerosis), autosomal dominant polycystic kidney disease, syndrome cassenoisette (compression of the left renal vein in the arterial clamp aortomésentérique), renal trauma can cause hematuria. Hematuria is fairly common among hemophilia. Hematuria in an anticoagulated subject requires etiological investigation.
Finally remember that kidney disease can be the cause of hematuria: Alport syndrome in young adults (permanent microscopic hematuria persists in between) or glomerular nephropathy immunogluline A (IgA) (where often macroscopic hematuria is contemporary with febrile respiratory infection and where microscopic hematuria may disappear from bleeding), post-infectious acute glomerulonephritis, rapidly progressive glomerulonephritis (antineutrophil cytoplasmatic antibodies often [ANCA] positive) or more rarely, Acute interstitial nephritis.
Various investigations (endoscopy, kidney ponctionbiopsie, arteriography, urine cytology, etc.) may be useful in a second time. Macroscopic hematuria with no identifiable cause are increasingly rare today.
Microscopic hematuria detected by examination of fresh urine dipstick is fairly common in the general population (4-5%). Hematuria is confirmed by urine culture if needed. Indeed the strip detects hemoglobin (and myoglobin) but hemoglobinuria or myoglobinuria are very rare, occurring in a particular context.
Other ways to quantify haematuria have no interest. Tedious, they have value only if the review includes freshly voided urine. Direct examination of fresh urine is commonly practiced in some countries to study the morphology of red blood cells: distorted, “sea urchins” when the glomerular bleeding, the bleeding is normal when urological. This test is not often used in France.
Many microscopic hematuria, especially mild to moderate or intermittent, do not correspond to a detectable lesions of the kidney and urinary tract. The problem is to identify microscopic hematuria require special investigations or surveillance.
We must clarify whether microscopic hematuria is isolated or not:
– Isolated: without proteinuria (possibly without pathological microalbuminuria) or kidney or urinary history or high blood pressure, or kidney failure, kidney with ultrasound and normal bladder. Settle for a check-up a year later.Some topics that retain an isolated microscopic hematuria, permanent and frank with chronic glomerular disease: benign familial hematuria (with thin glomerular basement membranes), IgA nephropathy, Alport syndrome in the heterozygous state; the possible indication of renal biopsy depends on the clinical contact;
– Not isolated: associated with one or more anomalies mentioned above (hematuria proteinuria + = + glomerular disease exploring family history of hematuria = hereditary kidney disease to identify; hematuria + = bladder tumor consulting a urologist etc.).
It is abundant and permanent microscopic hematuria, occurring in a matter of 40-50 years, smoker. Do not ignore a tumor of the urinary tract: provide IVU, urinary cytology and cystoscopy, although ultrasound is normal, as a beginner infiltrative tumor can be ignored.