Hematuria

Overview of Hematuria

Diseases due to kidney malfunctions are becoming very common especially in the low and middle-income countries lacking substantial knowledge related to hygienic urinary habits. According to the reports of the National Kidney Foundation, nearly 10% of the global population suffers from chronic kidney diseases. Million fatalities are reported annually due to lack of proper treatment leading to renal failure. Among the numerous kidney dysfunctions, the most threatening one is “Hematuria” or “blood in urine”. It has been observed that most patients (especially women) suffering from urinary tract infections are prone to hematuria at some point in time.

What is hematuria?

Hematuria is defined as the clinical condition where excess red blood cells (RBC) are present in urine, giving it a reddish-brown coloration. According to the American Urological Association, the presence of 3 or more RBCs per high power field (HPF) microscopic analysis of 2 or 3 collected samples of urine can be termed as “Hematuria”. The disease is an indicator of urological dysfunctions of severe nature. Typically, this disease has two subtypes- Microscopic and Macroscopic. Excerpts from National Kidney Foundation Reports show that 4% of patients suffering from Microscopic Hematuria and 40% of patients suffering from Macroscopic Hematuria could grow malignancy at some later stage.

What are the causes of Hematuria?

Hematuria is mainly caused due to the presence of red blood cells in the urine due to various clinical factors or diseases of the kidney. The generalized etiological factors are as follows-

• Cystitis: It is caused due to the formation of cysts in kidneys and few other vital organs like the liver, pancreas, and ovaries. Cystitis leads to the destruction of the renal parenchyma with the gradual enlargement of the cyst. This is a genetic disorder and is more common in women. It is characterized by a burning sensation during urination and the urge to urinate frequently.
• Kidney stones: Presence of kidney stones can cause blood in urine especially when these stones (the large ones) try to pass through the urine. An acute pain extending from the loin to the groin can occur in this case.
• Bladder/kidney tumors: This is more evident in people above 40 and is caused due to tumor outgrowths, cysts, inflammations, and stones in the bladder or kidney. In this case, the urine is unclear and has an obnoxious odor.
• Glomerular diseases: Erosion and thinning of the glomerular basement membrane produce gaps in the membrane which allows the RBCs to escape, which are then passed into the urine. Hematuria is also caused by glomerular bleeding due to deformed (dysmorphic) RBCs, which lead to glomerulonephritis. These conditions are caused by low serum levels. This can eventually lead to inflammation of the kidney and kidney failure and may be accompanied by High Blood Pressure.
• Polycystic Kidney Disease: It is usually present at birth and manifests itself at a later stage.
• Coagulation disorders: Few inherited diseases like Haemophilia or few anti-coagulant drugs impede normal blood coagulation mechanism and cause blood in urine.
• Sickle cell disease: It is caused by degeneration of RBCs in the renal medulla that leads to renal disorders. This condition is normally hereditary and is more prominent in a few ethnic groups.
• Intravascular Haemolysis: It is caused by the breakdown of Red Blood Cells into the bloodstream that finally passes via urine. This condition arises due to genetic disorders like paroxysmal hemoglobinuria.
• Malignancy: Malignancies due to renal masses (simple or complex cyst) can cause internal bleeding and hematuria.
• Bacterial infection: Urinary infections mediated by Escherichia coli bacteria can cause Hematuria.
• Diet: At times the intake of foods like beet can cause a reddish discoloration of urine.
• Rigorous exercise
• Surgical instrumentation
• Excessive intake of tobacco or alcohol
• Benign Prostatic Hyperplasia (BPH) in men
• Menstrual cycle

What are the symptoms of Hematuria?

Symptoms of Hematuria may not be very prominent in the initial stages (or for Microscopic Hematuria) but are clearly manifested in the advanced stages (or for Macroscopic Hematuria). These are as follows-

• Reddish or brownish discoloration of urine
• Urine turns cloudy and unclear
• An obnoxious odor of urine
• Urine leakage (due to lack of bladder control)
• Burning sensation while urinating
• Frequent need to urinate
• Difficulty passing urine
• Passing inadequate urine despite intense urge to urinate
• Persistent pain and feeling of pressure in the lower abdomen, pelvic region and lower back
• Mild fever and occasional chills
• Nausea and vomiting

What are the types of Hematuria?

Depending on the amount of blood present in urine, Hematuria can be classified into two categories-

• Microscopic Hematuria: It is characterized by the presence of trace amount of blood in the urine (2-3 RBCs per hpf of the urine sample) and is normally detected with a microscope.
• Macroscopic Hematuria: Significant quantity of blood in the urine (>10 RBCs per hpf of the urine sample) is observed and is characterized by dark-brown urine with occasional blood clots.

Depending on the origin, Hematuria can be classified into two categories-

• Glomerular Hematuria: It normally originates from the kidney and is caused by deformed RBCs, renal parenchyma destruction and presence of excess protein in the urine.
• Non-glomerular Hematuria: It is caused by Upper and Lower urinary tract infection and is characterized by the formation of urinary tract stones, prostate enlargement or renal malignancies.

Diagnosis

An abdominal X-ray is essential for the determination of the cause of Hematuria in the first place. An MR or CT Urography can be conducted to fully examine the bladders, ureters, and kidneys. Intravenous Pyelogram (IVP) is recommended in a few cases to investigate any abnormal functioning of the kidney.

Treatment & Prevention

The treatment of hematuria depends on the exact cause. There are several reasons that could result in blood appearing in the urine. Most common ones include kidney stones, enlarged prostate, urinary tract infections, bladder stones, bladder cancer, Lupus nephritis, high blood pressure and many more.  The main treatment methods are:

• Antibiotic medications in case of infections such as UTIs or urethritis.
• Medications that help in shrinking stones (bladder or kidney).
• Shockwave therapy to break the bladder or kidney stones.
• In many cases, treatment might not be even necessary.

Hematuria can be prevented by:

• Drink plenty of water to flush out the toxins from your system.
• Urinate immediately after sexual intercourse.
• Practice proper hygiene.
• Refrain from eating foods with high acidic and salt content.
• Refrain from smoking or any other form of tobacco consumption. This is the leading cause of bladder cancer.
• Limit exposure to environmental toxins and carcinogens such as toxic metals, harmful radiations, and harsh chemicals.

References