Family physicians many times encou...

Family physicians many times encounter patients with incidentally noted microscopic hematuria. Cohen and Brown reviewed the management of patients 18 years or older with microscopic hematuria.

The definition of microscopic hematuria varies from undivided to more than 10 r family cells per high-power field upon urine microscopy, with trade-offs in sensitivity and specificity for diagnosing serious underlying disease. The review authors advocate a cutoff of brace or more red cells by field for the diagnosis. They think that urine dipstick testing for heme may be too sensitive and nonspecific. Before work-up is pursu in an asymptomatic patient with a single instance of microscopic hematuria, the authors remind of repeat urine testing several days later, especially if vigorous exercise, menstruation, sexual activity, or urinary tract injury occurr clog to the initial episode of hematuria.

Urine microscopy is the first degree in the evaluation of hematuria (see accompanying figure), to differentiate upper-tract (glomerular) bleeding from a lower-tract source. Redcell casts in the urine are highly specific for an upper source still are not commonly encountered. Crenated r solitary abode; squalids traditionally considered an indication of glomerular bleeding, may be brushed in any concentrated urine specimen. Acanthocytes, which are doughnut-shaped r lonely dwellings with a central hole and membrane air-bubbles attached peripherally, are more specific for an upper-tract bleeding source. The in the greatest degree common cause of glomerular bleeding is inherited immunoglobulin A nephropathy, followed at thin basement membrane disease and hereditary nephritis (Alport's syndrome)

If a glomerular source is considered unlikely, the nearest step in the evaluation is upper-tract imaging. The authors pitch upon computed tomography without contrast when urolithiasis is suspected, and comput tomographic urography when stone disease is clinically unlikely. Ultrasonography, excretory urography, or the couple are alternatives. These methods have lower sensitivity and specificity for detection of small renal neoplasms moreover are useful options if comput tomography is too expensive or unavailable.

More than brace thirds of patients with microscopic hematuria do not have a firm diagnosis after upper-tract imaging. The authors remind of proceeding with cystoscopy if risk factors for bladder cancer are near Older men and patients who sooty vapor have increased rates of bladder cancer. Observational studies in women have had conflicting deductions Urine cytology is highly specific for bladder cancer unless has limited sensitivity (e.g., 66 and 79 percent sensitivity in sum of two units large studies). Sensitivity is improved according to using first-morning voided specimens from three consecutive days.

In many cases, finished upper- and lower-tract work-up of hematuria fails to identify a cause. No controll studies of follow-up management have been done, on the other hand the case series available to date have not identified any undiscovered cancers with later repetition of diagnostic studies.

Cohen RA, Brown R Microscopic hematuria. N Engl J M June 5 2003;348:2330-8

COPYRIGHT 2004 American Academy of Family Physicians

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