血尿臨床思路

Hematuria 在臨床上很常見   茲將臨床思路整理如下

先看病人是哪一種血尿
1.  如果是gross hematuria(肉眼可見): 考慮泌尿道問題=>
若病人無外傷或UTI=>考慮影像學檢查(CT, renal echo, IVP)=>r/o malignancy, nephrolithiasis
                                  => cystoscopy=> r/o BPH, bladder tumor

2. 若為microscopic hematuria(>=3/HPF): 先驗sediment=>確定是否真的為血尿
因為若只有驗U/A=>未必為真正血尿(可能受myoglobulin, MC影響)

=> 若sediment 亦為postive=> confirm hematuria
=>  可藉由病史詢問 , PE and U/A=> 確認是否為UTI, APN,MC, recently urological surgery影響
=> 看sediment 是否有dysmorphic RBC, RBC cast, WBC cast
=> 若有=>考慮medical renal disease=> 包括glomerulonephritis, nephrotic syndrome, AIN....
(亦需沿下面流程r/o urinary tract tumor)
=> 若無=> consider malignancy risk
=> if high risk=> CT=>r/o malignancy, nephrolithiasis
=>if low risk or contrast allergy or poor renal function=> MRI,non-contrast CT, renal echo=> r/o malignancy, nephrolithiasis

=> cystoscopy=> r/o BPH, bladder tumor


reference:
1. Harrison's principles of internal medicine
2. AUA guidelinde
3. AAFP website
4. Massachusetts pocket medicine of internal medicine