Microscopic Hematuria Causes in Adults

Aka: Microscopic Hematuria Causes in Adults, Adult Microscopic Hematuria Causes, Hematuria Causes

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II. Background

  1. Consider non-urine source (e.g. vagina or Rectum)

III. Causes: Most common of adult Hematuria by history

  1. Age
    1. Age <20 years
      1. See Pediatric Hematuria
      2. Glomerulonephritis
      3. Urinary Tract Infection
    2. Age 20-40 years
      1. Ureterolithiasis
      2. Urinary Tract Infection
      3. Urinary Tract Cancer (less common)
    3. Age 40-60 years
      1. Urinary tract cancer (up to 10% of cases)
      2. Ureterolithiasis
      3. Urinary Tract Infection
    4. Age >60 years
      1. Urinary tract cancer (up to 10% of cases)
      2. Prostatic Disease (e.g. Benign Prostate Hyperplasia)
  2. Timing
    1. Gross Hematuria on initiating urine stream
      1. Bladder or Urethral source
    2. Gross Hematuria at end or urination
      1. Prostate source
    3. Gross Hematuria throughout urination
      1. Renal Source
    4. Cyclical Gross Hematuria
      1. Consider Endometriosis
  3. Hematuria with pain
    1. Nephrolithiasis
    2. Renal Vein Thrombosis
    3. Renal Artery Occlusion
    4. Renal Cancer
  4. Hematuria with Dysuria
    1. Hemorrhagic cystitis (Urinary Tract Infection)
    2. Prostatic infection
    3. Bladder stones
  5. Hematuria with history of Trauma
    1. Urethral disruption (seen in pubic Fracture)
    2. Bladder injury (seen in Pelvic Fracture)
    3. Renal Laceration or rupture
  6. Hematuria based on Urine Color
    1. Brown Urine: Gross Hematuria (or other causes of Brown Urine)
    2. Urine clots: Post-renal source of bleeding

IV. Causes: Asymptomatic Microscopic Hematuria by Incidence

  1. Benign essential Hematuria (37%)
  2. Benign Prostatic Hyperplasia (24%)
  3. Urethral Infection (21%)
  4. Urinary Tract Infection (7%)
  5. Nephrolithiasis (4%)
  6. Urethral calculus (2%)
  7. Bladder tumor (2%)
  8. Renal Cyst (1.5%)
  9. Renal tumor (0.5%)

V. Causes: Most important to rule-out (cancer and aneurysm)

  1. Bladder and Urethra Disease
    1. Bladder Cancer
    2. Urethral cancer
    3. Penile Cancer
  2. Kidney and ureter disease
    1. Ureteral transitional cell cancer
    2. Renal Cell Cancer
    3. Renal transitional cell cancer
    4. Renal Lymphoma
  3. Prostate Disease
    1. Prostate Cancer
  4. Miscellaneous
    1. Metastatic cancer
    2. Abdominal Aortic Aneurysm

VI. Causes: Important to Treat

  1. Bladder and Urethra Disease
    1. Urinary Tract Infection
      1. Acute Cystitis
      2. Pyelonephritis
      3. Mycobacterial cystitis
    2. Bladder calculus
    3. Urethral Stricture or meatal stenosis
    4. Bladder papilloma
  2. Kidney and ureter disease
    1. Renal parenchymal disease
    2. Ureteropelvic junction obstruction
    3. Nephrolithiasis
    4. Vesicoureteral reflux
    5. Hydronephrosis
    6. Renal Artery Stenosis
    7. Renal vein thrombosis
  3. Prostate Disease
    1. Symptomatic Benign Prostatic Hyperplasia
    2. Prostatitis

VII. Causes: Important to Observe

  1. Prostate Disease
    1. Asymptomatic Benign Prostatic Hyperplasia
  2. Bladder and Urethra Disease
    1. Radiation cystitis
    2. Bladder Diverticulum
    3. Bladder neck contracture
    4. Interstitial Cystitis
    5. Cystocele
    6. Neurogenic Bladder
    7. Eosinophilic cystitis
    8. Phimosis
  3. Kidney and ureter disease
    1. Atrophic Kidney
    2. Papillary necrosis
    3. Renal Arteriovenous Fistula
    4. Renal Contusion or Trauma
    5. Polycystic Kidney Disease
    6. Ureterocele
    7. Interstitial Nephritis (Gold, Penicillamine, NSAIDs)
    8. Glomerular Causes - Primary
      1. See Glomerulonephritis Causes
      2. Focal Segmental Glomerulosclerosis
      3. Goodpasture Syndrome
      4. Henoch-Schonlein Purpura
      5. Mesangial proliferative Glomerulonephritis
      6. Postinfectious Glomerulonephritis
      7. Rapidly Progressive Glomerulonephritis
      8. IgA Nephropathy (Berger Disease, associated with infectious disease)
    9. Glomerular Causes - Secondary
      1. Hemolytic Uremic Syndrome
      2. Lupus Nephritis
      3. Thrombotic Thrombocytopenic Purpura
      4. Vasculitis
    10. Glomerular Causes - Familial
      1. Fabry Disease
      2. Alport's Hereditary Nephritis (Alport Syndrome)
      3. Nail-Patella Syndrome
      4. Thin glomerular basement membrane disease (50%)

VIII. Causes: Benign

  1. Bladder and Urethra Disease
    1. Inflammation of the Urethral trigone
    2. Urethral polyp or Bladder neck polyp
    3. Bladder Varices
    4. Trabeculated Bladder
    5. Urethritis
  2. Kidney and ureter disease
    1. Pelvic Kidney
    2. Renal Cyst
    3. Duplicate collecting system
    4. Scarred Kidney
    5. Calyceal Diverticulum
  3. Prostate Disease
    1. Prostatic stone
  4. Miscellaneous
    1. Athletes with RunningTrauma (March Hematuria, exercise Hematuria)
      1. Hematuria transiently related to activity
      2. Recheck Urinalysis in 2 weeks

IX. Causes: By Category

  1. Glomerular
    1. See Glomerulonephritis Causes (includes Rapidly Progressive Glomerulonephritis)
    2. Primary Glomerulonephritis
      1. Focal Segmental Glomerulonephritis
      2. Goodpasture Syndrome
      3. Henoch-Schonlein Purpura
      4. IgA Nephropathy
      5. Poststreptococcal Glomerulonephritis (and other Postinfectious Glomerulonephritis)
      6. Mesangial Proliferative Glomerulonephritis
    3. Secondary Glomerulonephritis
      1. Hemolytic Uremic Syndrome
      2. Systemic Lupus Erythematosus (Lupus Nephritis)
      3. Thrombotic Thrombocytopenic Purpura
      4. Vasculitis
    4. Familial
      1. Alport Syndrome
      2. Fabry Disease
      3. Nail Patella Syndrome
      4. Thin basement membrane nephropathy
  2. Other Renal Causes
    1. Medullary sponge Kidney
    2. Polycystic Kidney Disease
    3. Renal papillary necrosis
    4. Sickle Cell Disease
    5. Loin Pain Hematuria Syndrome
    6. Vascular Causes
      1. Malignant Hypertension
      2. Renal Arteriovenous Malformation
      3. Renal Artery Embolism (e.g. endocarditis)
      4. Renal Vein Thrombosis
    7. Metabolic Causes
      1. Hypercalciuria
      2. Hyperuricosuria
  3. Urologic Causes
    1. Benign Prostatic Hyperplasia
    2. Urologic Malignancy (see above)
    3. Urinary Tract Infection (cystitis, Pyelonephritis)
    4. Uretherolithiasis or Nephrolithiasis
    5. Prostatitis
    6. Foley Catheter
    7. Athletes with RunningTrauma (March Hematuria, exercise Hematuria) - see above
    8. Infections
      1. Schistosoma haematobium
      2. Tuberculosis
  4. Medications
    1. See Medication Causes of Hematuria
    2. See Interstitial Nephritis
    3. Warfarin, Heparin or other Anticoagulants (if associated with urologic anomaly)
    4. Cyclophosphamide
    5. Gold
    6. Penicillamine
    7. NSAIDs

X. References

  1. Swadron (2019) CCME Emergency Board Review, accessed 5/18/2019
  2. Ahmed (1997) Med Clin North Am 81(3): 641-52 [PubMed]
  3. Grossfield (1998) Urol Clin North Am 25:661-76 [PubMed]
  4. Hitzeman (2022) Am Fam Physician 106(1): 27-35 [PubMed]

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