Hematuria, either gross or microscopic, is one of the more common problems
presenting to Urologists for evaluation, accounting for up to 15 percent of hospital
admissions to Urology services. It creates obvious concerns to patients; especially those
with grossly bloody urine. There are varying degrees of urine, from one to three RBC/HPF
to gross blood. The normal population will have some degree of microscopic hematuria and
in fact up to three RBC/HPF is considered within normal limits. Any degree of true
microscopic hematuria (>3 RBC/HPF) that persists on two or more examinations, or gross
hematuria requires an evaluation for life threatening conditions.
Strenuous exercise, urinary tract instrumentation, and menstruation may induce
hematuria, and therefore, evaluations for microscopic hematuria should be performed
greater than 48 hours after exercise or instrumentation, or 2 weeks after menses to obtain
the most accurate results. Urinalyses positive for blood on dipstick must be followed by a
quantitative microscopic examination for red blood cells, as false positive results can
occur in normal states as well as patients with myoglobinuria.
The differential diagnosis for hematuria is large, and includes conditions such as
UTIs (most common), urolithiasis, renal or urothelial tumors, trauma, hemangiomas or
arterio-venous malformations, glomerulonephritis (commonly in association with significant
proteinuria), strictures, benign prostatic hyperplasia (BPH), or urethritis.
The work-up for hematuria, gross or microscopic, includes studies to diagnose the
life threatening conditions that cause hematuria. History and physical examination will
frequently elucidate the diagnosis, as in many other medical conditions. Urothelial or
renal tumors are most common in the older population > 50 years old, especially in
those with a history (past or present) of smoking or exposure to aniline dyes, benzene
ring petroleum products, phenacetin-containing analgesics. Over 25 percent of men and
women with gross hematuria will be found to have life threatening diseases, most commonly
transitional cell carcinoma. Microscopic hematuria in women < 40 years of age have <
2 percent risk of a significant diagnosis. Urine culture must be obtained, even in
asymptomatic patients, as infection is the most common cause of all hematuria.
Upper tract imaging is necessary to rule out renal or collecting system pathology, and
can be accomplished in one of a number of ways. Intravenous urogram for patients without
known contrast allergy and with normal renal function is the initial study of choice to
image the kidneys and collecting system. Lesions, abnormalities, or incomplete studies
will prompt further investigation. Ultrasound, MRI, or CT scan may be warranted. To
further evaluate the ureters or renal pelvis, retrograde pyelogram is the study of choice
and can be performed by a urologist at time of cystoscopy, another necessary procedure in
the evaluation of hematuria. Filling defects or distortion of the ureters or pelvicalyceal
system may prompt inspection with ureteroscopy, as stones or tumors are frequently
Urine cytologies may be of assistance in the initial evaluation to identify patients
with high-grade transitional cell carcinoma or carcinoma-in-situ. Three voided samples can
be obtained prior to the patients visit with the urologist, however, these must not
be the first morning urine collected. Degenerated urothelial cells in the first morning
urine may give false positive results initiating an unnecessary and invasive work up.
Annual urinalysis and cytologies should follow negative evaluations for 3 years. If no
progression of hematuria or positive cytologies occur, the evaluation is finished. For
recurrent or worsening hematuria, a complete repeat work up in indicated.
Phimosis is the condition in which the prepuce (foreskin) cannot be retracted to
expose the glans penis. This condition is commonly associated with diabetes mellitus or
recurrent episodes of balanitis, which lead to a circumferential scar or phimotic ring. As
long as the patient is able to void, emergent treatment is unnecessary, and the patient
can undergo elective circumcision. If the phimosis is due to massive edema, an ACE wrap
can be sequentially applied from distal to proximal forcing the tissue fluid out of the
prepuce. Alternatively, one can hold circumferential pressure on the penis for 5-10
minutes for the same effect. Occasionally, oral or parenteral sedation is necessary for
the patient to allow manipulation of the phallus.
For a fixed preputial ring, a dorsal slit is necessary and recommended. Sterile
technique should be observed. Using 1% or 2% xylocaine WITHOUT EPINEPHRINE, a wheal
is raised in the dorsal midline of the inner and outer foreskin in the midline for 3-4
centimeters. The incision can always be extended, but avoid making the dorsal slit all the
way to the corona. Place a straight clamp on the anesthetized skin and click it closed
twice for approximately 5 minutes. This will cause the skin to appear blanched when the
clamp is removed, and will reduce the amount of bleeding encountered. With scissors, cut
the skin in the midline. The inner and outer preputial skin edge can be oversewn using an
absorbable 3-0 or 4-0 chromic or monocryl suture on a non-cutting needle in a simple
running pattern. Never leave a circumferential pressure dressing on the penis, as this
could compromise the blood supply to the glans and cause tissue necrosis.
Paraphimosis is the inability to reduce a retracted foreskin back over the glans
penis. This skin acts as a constricting ring and reduces blood flow to the distal phallus.
This is an emergency. Patients are in severe pain, and frequently require narcotic
analgesics to reduce the paraphimosis. Placing considerable pressure on the glans to push
it back through the constricting tissue can do this. Surgical sponges may be necessary to
obtain an adequate hold on the phallus and prepuce. Once reduced, a dorsal slit as
described above can be performed.
Balanitis is inflammation of the glans penis. It is commonly encountered in men
with poor genital hygiene, failing to retract the foreskin and clean the tissue beneath.
In a military setting, the uncircumcised male living in the field is most at risk. Severe
pain, redness and edema are common complaints. The treatment consists of the local
application of antibiotic cream or ointment and diligent attention to personal hygiene.
Warm soaks and non-steroidal anti-inflammatory medications will aid in reducing the
discomfort and edema. Occasionally, oral antibiotics to cover common skin organisms are
required to eradicate the condition. If the situation becomes chronic, elective
circumcision in the absence of inflammation is the appropriate treatment.
Prostate cancer screening
The current recommendations by the American Urologic Association and the American
College of Surgeons include an annual PSA blood test and digital rectal examination (DRE)
for all men 50 years old and over. Screening should being at the age of 40 for those at
high risk for prostate cancer at an early age. They include all African-American men, and
all men with first degree relatives diagnosed with prostate cancer.
Patients should be referred for evaluation by a Urologist for any abnormal DRE
(asymmetry or palpable nodule) regardless of PSA
value, or a PSA greater than 2.5 ng/ml in
all African-American men or Caucasian men less than 55 years old. For all other men, a
PSA greater than 4.0 ng/ml is sufficient for referral.
Pediatric Urology: Request for Circumcision
Many parents request circumcision after the newborn period if, for medical, social
or personal reasons, the circumcision was not performed at birth. Medical indications to
perform circumcision at this age are few, however, the parents wishes should be honored.
The child should be referred to a Urologist and the elective circumcision performed free
hand after six months age when the risks of anesthesia are minimized.
UTIs in children
Any child with a urinary tract infection must be referred to a pediatric urologist
for evaluation. Up to 50 percent of these children will have vesicoureteral reflux which,
if left untreated, can lead to renal scarring, hypertension, and renal failure. Once the
acute infection is cleared with appropriate antibiotic treatment, the child must be placed
on prophylactic antibiotics once a day to decrease the risk of a recurrent infection until
the work-up is complete. A renal ultrasound should be performed to assess the size of the
kidneys as well as the collecting system for dilatation. This study will not, however,
rule in or rule out reflux. This must be done with a contrast or nuclear voiding
cystourethrogram (VCUG). Bactrim or
septra, amoxicillin, cefixime, or
be reasonable for prophylaxis. Do not use fluoroquinolones in children due to their
association with premature closure of epiphyseal plates.
Any child being evaluated for a febrile illness should be assessed for a urinary tract
infection with a urinalysis and culture. Children do not exhibit the classic irritative
voiding symptoms as seen in adults with UTIs, but may complain of vague abdominal pain,
anorexia, or malaise.
Enuresis, or nocturnal incontinence, is concerning to many parents as
children advance to and past their toilet training years. Twelve percent of children ages
4 to 5 will wet the bed, with a resolution rate of 15 percent per year to the age of 19.
Family history is generally predictive of what age a child will become dry at night.
Encouraging fluid intake and urinating frequently during daytime, having the child void
before going to bed, limiting the amount of fluid a child drinks several hours before
bedtime, and bedwetting alarms all have shown success in helping these patients.
Reassurance for the parents that this condition will resolve is important.
In the military recruit population, enuresis must be fully evaluated by a urologist. If
the condition existed before enlistment (EPTE), the member may be administratively
released from active service, as this is a disqualifying condition.
Submitted by CAPT M. Melanie Haluszka, MC, USN, LCDR Brian K. Auge, MC, USN, and
LT Timothy F. Donahue, MC, USNR, National Naval Medical Center, Bethesda (1999).
Approved for public release; Distribution is unlimited.