Hematuria — History Taking

Definition

• Gross (macroscopic) — visible to the naked eye; often alarming to the patient
• Microscopic — detected only on urinalysis (≥5 RBCs/μL of urine); frequently asymptomatic

Key History Points

1. Characterize the Hematuria

• Timing during micturition — highly localizing:
  • Initial hematuria (only at the start of stream) → urethral pathology
  • Total hematuria (throughout the stream) → bleeding above the bladder neck (kidney, ureter)
  • Terminal hematuria (at the end of stream) → bladder neck, posterior urethra, or prostate
• Color: pink/red vs. tea/cola-colored (tea color suggests glomerular origin — hemoglobin oxidation)
• Presence of clots: passage of blood clots suggests a non-glomerular source (tumor, stone, trauma)
• Transient vs. persistent vs. recurrent episodes

2. Associated Urinary Symptoms

• Dysuria, urinary frequency, urgency → infection (cystitis, pyelonephritis, prostatitis)
• Colicky flank pain → nephrolithiasis or ureteric pathology
• Irritative voiding symptoms (frequency, urgency, dysuria) without infection → urothelial malignancy (bladder cancer)

3. Risk Factors for Malignancy (Critical HPI Elements)

• Age (urothelial cancer risk rises >40 years)
• Smoking history — the single strongest risk factor for bladder cancer
• Industrial chemical exposure — aniline dyes, aromatic amines, benzene (occupational risk)
• Analgesic abuse (phenacetin) → transitional cell carcinoma
• Alkylating chemotherapy (cyclophosphamide) → hemorrhagic cystitis, bladder cancer
• Chronic foreign bodies in the urinary tract
• Pelvic radiation history

4. Preceding Events / Triggers

• Upper respiratory tract infection / sore throat / skin infection preceding hematuria by:
  • 1–3 days → IgA nephropathy ("synpharyngitic hematuria")
  • 2–3 weeks → post-streptococcal glomerulonephritis
• Recent strenuous exercise → exercise-induced transient hematuria (benign, resolves with rest)
• Recent trauma — blunt abdominal or flank trauma
• Recent urologic instrumentation or catheterization
• Menstruation — risk of sample contamination; interpret with caution

5. Systemic Symptoms

• Fever, chills → pyelonephritis or other infection
• Joint pain, skin rash → Henoch-Schönlein purpura (IgA vasculitis), lupus nephritis
• Edema, hypertension → glomerulonephritis or nephrotic syndrome
• Hearing loss or visual problems → Alport syndrome

6. Past Medical & Medication History

• Prior episodes of hematuria
• Known nephrolithiasis or renal colic
• Known kidney disease (glomerulonephritis, PKD)
• Sickle cell disease or trait → papillary necrosis, sickling in renal medulla
• Bleeding disorders / coagulopathy
• Recent travel (Schistosoma haematobium → bladder, endemic in Africa/Middle East)
• Anticoagulant use (warfarin, DOACs) — note: anticoagulants unmask rather than cause hematuria; full evaluation is still warranted
• Drugs associated with hematuria: NSAIDs, penicillin, anticonvulsants, diuretics, chlorpromazine, cyclophosphamide
• Drugs causing red-brown urine discoloration (pseudo-hematuria): rifampin, chloroquine, isoniazid, nitrofurantoin
• Foods: beets, rhubarb, blackberries

7. Family History

• Hematuria in relatives
• Hearing loss or ocular abnormalities → Alport syndrome (COL4A mutations)
• Progressive chronic kidney disease or ESKD
• History of dialysis or renal transplantation
• Nephrolithiasis / urolithiasis
• Hematologic abnormalities: sickle cell disease/trait, coagulation disorders
• Hypertension

Summary: Pattern Recognition from History