CC January 2015 Microhematuria

echoecho's version from 2015-05-20 15:10


Question Answer
Asymptomatic microhematuria (MH) during routine care of adults is frequently encountered, list the potential etiologies of MH?varies from common benign conditions (UTI, concurrent menstruation, vigorous exercise) to very serious conditions (nephrogenic and urologic malignancies)
In 2012, the AUA (American Urologic Association) updated their clinical practice guidelines. What did the expert panel underscore?the importance of applying clinician's experience, patient's unique clinical profie and community resources in the implementation of guidelines recommendations
There is controversy regarding the utility of a routine urinalysis in what type of patient?asymptomatic patient
While the test may identify yet undiagnosed disease, an assessment must be made of what?the risk of underlying disease vs. the risk of evaluation (imaging, invasive procedures, radiation and contrast exposure)
Why do some argue againt routine testing?due to the intermittent nature of findings such as blood and teh low incidence of significant urologic disease
The USPSTF states that there is insufficient evidence to warrant routine testing of all adults for microhematuria to detect _____ cancer?bladder
Less than ____% of pts with asymptomatic micro hematuria will have bladder CA?5%
Is there consensus regarding who should have testing? What should physicians do as a result?1) no 2) should make a determination based on the pt's hx, risk fxs, and physical exam
What test is often required components of exams required by other entities?urinalysis
The AUA defines microhematuria as what?presence of > 3 RBCs per HPF on a single, properly collected, noncontaminated urine that has no evidence of infection
In general, is a voided mid-stream specimen adequate for exam?yes
Why must microhematuria discovered by routine dipstick urinalysis be confirmed by microscopic urinalysis?because dipstick determination for blood is as sensitive as urine sediment evaluation, but not a specific
False positives can arise due to presence of 4 conditions?1) semen in the specimen 2) alkaline urine (pH > 9) 3) contamination with oxidizing agents used to clean the perineum 4) the presence of myoglobin
What 2 conditions can produce a false negative UA for microhematuria?1) vitamin C 2) markedly diluated urine
*** While the presence of dysmorphic red cells, cellular casts, proteinuria and/or eivdence of renal impairment should prompt early nephrology referral for evaluation of medical cuases, it does not preclude the need for concurrent urologic evaluation. The need for urologi evaulation is based on what?pt risks and clinical presentation
List common medical renal causes of microhematuria?1) IgA nephropathy 2) thin basement membrane disease (benign familial hematuria) 3) hereditary nephritis (Alport's syndrome) 4) polycystic kidney disease
***Initial evaluation of microhematuria after confirmation by microscopic urinalysis should includ a thorough hx and urological exam as well as assessment of renal function by what 2 tests?creatinine, GFR
Providers should identify and treat underlying benign conditions (infections) promptly and repeat ____ after completeting treatment?UA
Persistent microhematuria after appropriate treatment warrants what?full work-up
*** Patients with a positive dipstick for microhematuria but negative microscopic urinalysis should have _____ additional follow-up microscopic urinalysis?3
If one of the follow-up urinalysis confirms microhematuria, what is recommended?full work-up
If all 3 microscopic urinalysis are normal, what is recommended? In this scenario, providers may consider it a false - _____ dipstick for microhematuria?1) no further evaluation for microhematuria 2) positive
Patients taking anticoagulants (warfarin) or ASA, what is recommended for their work-up?should undergo usual work-up if urinalysis confirms microhematuria regardless of the typ or level of anticoagulation
In a recent study, is there a difference in the incidence of microhematuria among ASA users and nonusers?no
Can it be assumed that the microhematuria is due to the anticoagulation?no
***Evaluation of confirmed microhematuria routinely requires imaging of what?upper and lower urinary tract
***The current AUA guideline recommends what imaging? Why?1) multi-phasic computed tomography (CT) urography (with and w/o contrast) 2) as it has the highest sensitivity and specificity for identifying underlying nephrogenic and urologic etiologies
The use of a multi-detector CT (MDCT) offers optimal imaging information. List what it includes?1) pre-enhanced phase (calculi, hydronephrosis or hematoma) 2) arterial phase (neoplastic or inflammatory neovascularity) 3) parenchymal phase (pyelonephritis or neoplastic lesions) 4) excretory phase (collecting system, ureters, bladder, and urothelial pathology as filling defects)
What is the disadvantage of multi-detector CT (MDCT)? exposing pts to significant radiation (7.7 mSv vs. 3 mSv with IVP and contrast media)
What are the contraindications for multi-detector CT (MDCT)?1) contraindicated in pregnancy 2) contraindicted in pt with severe contrast media allergies or impaired function
In pts who can't have MDCT urography, what other 2 recommended options can be used?1) magnetic resonance (MR) urography (w/ w/o contrast) 2) retrograde pyelography (RP)
What imaging option is there for pts for whom MRI and MDCT are contraindicated?noncontrast CT or US combined with RP will allow upper tract evaluation
The AUA recommends what imaging studies for pregnant women (recognizing the risk of malignancy in this population is low)1) MR urography 2) MRI with RP (retrograde pyelography) 3) US
In the pregnant women, a full work-up should be completed when?after the delivery
*** What is recommended for all patients > 35 years of age with microhematuria?cystoscopy
*** In patients < 35 years of age, cystoscopy recommendations?can be performed at the provider's discretion
***List the 10 common risk fxs for urinary tract malignancies?1) 35 years or older 2) male sex 3) current or past hx of smoking 4) hx of exposure to chemicals and dyes (benezenes or aromatic amines) 5) hx of pelvic radiation 6) irritative voiding symptoms 7) hx of exposure to known carcinogens such as cyclophosphamide and other alkylating agents 8) hx of gross hematuria 9) hx of analgesic abuse 10) hx of chronic urinary tract infection
What lab tests, in addition, should be routinely performed in patients with microhematuria? Why?1) urine cytology 2) urine markers (NMP22, BTA-stat and UroVysion FISH) 3) because lack of sensitivity and specificity
False positive tests may subject patients to what?unnecessary risks and expense of biopsy
For pts w/ persistent microhematuria following an initial negative work-up and/or with presence of risk factors for malignancy, AUA states what exam may still be useful for further evaluation?cytology
Regarding the need for repeated urologic evaluation of low-risk patients with persistent microhematuria following a negative initial evaluation, providers should f/u with _____ urinalysis and no further w/up is necessary after ____ consecutive negative urinalyses because the risk of future malignancy is low, < ___%? 1) annual 2) two 3) < 1%
A repeat full evaluation within ____ to ____ years after a negative initial work-up should be considered in pts w/ persistent or recurrent asymptomatic microhematuria (esp. in those who have risk fxs for urinary tract malignancies?3 to 5 years
These recommendations regarding follow-up are not limited to a certain ___ group, but applies to all adults, regardless of age?age