Hematuria

Hematuria is a common finding in our refugee patients. While we do not recommend routine urinalyses (UA) in asymptomatic patients, we regularly discover microscopic hematuria in patients tested for clinical reasons.

Microscopic hematuria is defined as ≥3 RBCs/high-power field on urine microscopy.

While our approach to hematuria in refugee patients is similar to the approach for the general population, a few additional elements (such as schistosoma and tuberculosis) have to be considered in this population. In young healthy patients, a cause is often not identified.

The following is our recommended approach for refugee patients with microscopic hematuria (this approach applies mainly to adult patients):

  1. Rule out schistosomiasis

Make sure schistosomiasis has already been ruled out as part of the initial screening tests in refugee patients from an endemic country (see Map). If not, then a schistosoma serology should be ordered.

Patients with schistosomiasis and concomitant microscopic hematuria should be treated (see Schistosomiasis) and the UA should be repeated at least 1 month after treatment. If microscopic hematuria is still found on the repeat UA, it is reasonable to re-treat the patient with a second dose of praziquantel since a single dose does not always kill all the adult worms. If microscopic hematuria is still present 1 month after the second praziquantel dose, the patient should then be investigated for another cause of hematuria.

  1. Complete the history and physical exam

Patients should be asked about any history of macroscopic hematuria* (red or brown urine) and/or blood clots, flank pain, pyuria, dysuria, increased urinary frequency, and urinary retention.

Inquire about any past or current smoking history. Ask about any familial or personal history of bleeding disorders and make sure sickle cell has already been ruled out as part of the initial screening process (since both the disease and the trait can cause hematuria). A sexual history should also be performed to assess the risk of STI.

Female patients should be asked if they had their period during or right before the urine test was performed. Patients should also be asked about any recent history of vigorous exercise or trauma. In these cases, a UA should be repeated with clear instructions: at least a few days before or after the patient’s period, not after any physical exercise, and at least a few weeks after any trauma.

All patients with hematuria should be screened for hypertension.

* In patients with macroscopic hematuria, the following steps can still be followed, but a Urology referral should be requested right away.
  1. Investigate common causes

In patients with microscopic hematuria, order the following tests:

- Repeat UA (to see if the hematuria is transient or persistent*)
- Urine culture & sensitivity and chlamydia/gonorrhea NAAT (treat if positive and repeat UA 6 weeks later)
- Serum creatinine**
- Urine microalbumin**
- Renal and bladder ultrasound

* Both cases should still be investigated, but this can give a clue about the underlying etiology.
​
** Proteinuria, elevated serum creatinine levels, RBC casts or dysmorphic RBCs on microscopy, hypertension, or “cola” urine suggest glomerular bleeding and a Nephrology referral is recommended in these cases.
  1. Rule out urinary TB

Patients with unexplained hematuria who are from a country with a high tuberculosis incidence (see Table) should be investigated for potential urinary TB. In these patients, at least 3 early-morning (first void) urine samples should be sent for acid-fast stain. A urine mycobacterial culture should also be performed.

  1. Referral

If the patient’s microscopic hematuria is still unexplained after the above investigations, a referral to a Urologist for cystoscopy is then warranted.