Hematuria
Blood in the urine may be either microscopic or macroscopic, the latter generally causing patients to come to the emergency department. In patients who present with “blood in the urine,” artifactual causes must be considered and excluded. These include hemoglobinuria, myoglobinuria, beet ingestion, and the use of phenolphthalein-containing laxatives. Although significant blood loss is unusual except in patients with bleeding secondary to trauma or anticoagulation, as in any patient with blood loss, hemodynamic stability should be evaluated early and corrected as needed.
COMMON CAUSES OF HEMATURIA
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Hemorrhagic cystitis
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Nephrolithiasis
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Pyelonephritis
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Acute prostatitis
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Urethral stricture
LESS COMMON CAUSES OF HEMATURIA NOT TO BE MISSED
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Genitourinary malignancy
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Papillary necrosis
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Renal infarction
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Genitourinary tuberculosis
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Glomerulonephritis
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Urethral foreign body
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Excessive coagulation therapy
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Traumatic urethritis
HISTORY
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The artifactual causes of hematuria are excluded by history.
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Fever, chills, suprapubic or flank pain, dysuria, frequency, and urgency suggest urinary tract infection with associated hematuria.
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Severe flank pain, often radiating to the lower quadrant or groin, associated with restlessness, diaphoresis, nausea, and vomiting should suggest nephrolithiasis. A personal or family history of renal calculi may be noted in addition.
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Fever, suprapubic or perineal pain, and referred testicular pain suggest acute prostatitis.
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Renal emboli with infarction should be considered in all patients with flank pain, atrial fibrillation, and hematuria.
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When hematuria occurs in the context of therapeutic anticoagulation, a structural abnormality occurring at some location in the genitourinary tract is likely.
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Urethral foreign bodies should be considered in all children with hematuria.
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Gross, painless hematuria in the patient with sickle cell trait should suggest papillary necrosis. Other causes of papillary necrosis, including diabetes mellitus and analgesic nephropathy, although usually not associated with gross hematuria, should be considered as well.

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