Re: microscopic hematuria testing & questions
From: David Rind (drind_at_caregroup.harvard.edu)
Date: 06/13/04
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Date: Sun, 13 Jun 2004 16:00:03 -0400
googleuser1968 wrote:
> Hi,
>
> 37 year old female. Non-smoker, infrequent drinker (6 or 7 drinks a
> year). No pregnancies (by choice). No complaints except menstrual
> cramps --- gyn said possible beginnings of endometriosis. Currently
> taking estostep & naproxin (when needed). White coat hypertension -
> but at home averages about 117/72 (highest diastolic reading being 83
> over a 2 month period of daily home testing).
>
> Was given a dipstick test as part of the regular ob/gyn check. Came
> back positive for blood. Had me give another sample for a more
> detailed test which also came back positive, also showed no infection.
> Sent me to a urologist 3 weeks later who also did a test which came
> back positive. Also did a physical exam which showed nothing.
>
> Now the urologist wants me to have my bladder scoped and check my
> kidneys with dye at the same time. I don't know much about this
> condition except what I've been researching on the net, so here are my
> concerns. Informed opinons on this matter are welcome...
>
> 1) I specifically asked him if it was glomerular or nonglomerular. He
> seemed taken aback by the question, then looked confused, then said he
> was going to "treat it as nonglomerular". Which leads me to believe
> that either he couldn't tell from the sample or didn't bother to
> check. I wonder if sometimes it is difficult to determine or if he
> dropped the ball on this.
>
> 2) I asked him if he was planning on doing any blood work. He said
> no, not unless something came back from the scoping. When I asked if
> he didn't want to rule out some problems first, he said that if there
> were problems, I'd have other complaints like swollen feet or that
> they would have found protein in my urine.
>
> He also went on to say that usually nothing shows up on the scope so I
> didn't need to be overly concerned. When I asked if my scope test
> turned out to be negative would I need to worry about it anymore, he
> replied that I should just "keep an eye on it". When I asked him to
> define what that meant, he said that I should have a test done every
> once in awhile to check for problems (like when I see my ob/gyn).
> This seems odd to me, if blood has shown up twice, isn't it likely to
> continue to show up? If so, what is the benefit of the occasional
> testing when I already know it will come back positive?
>
> Also, he led me to believe that nonglomerular was more likely to be
> caused by something physical like a blockage or tumor and glomerular
> would be from a disease affecting my kidneys, etc. If so, isn't it
> important to determine which one it is first?
>
> I am willing to endure necessary tests, but I don't want to have to
> put up extra invasive testing if I don't need it.
>
> Thank you,
> Want to be an informed patient
You seem to be doing well on the well-informed patient thing.
First, performing screening urine dipsticks is not recommended,
and part of the reason is illustrated by this situation where
a probably healthy person is found to have an "abnormality" that
in the end is likely to turn out to be nothing.
That said, once someone is found to have blood in their urine,
most doctors feel obligated to pursue the diagnosis.
An Ob/Gyn is not likely to be the best person to do this. Ideally,
this should be handled by someone with more internal medicine training.
That said, a lot of family physicians and internists are likely to
have problems with the workup as well, in part because what is written
as being recommended is not always appropriate.
The decision to pursue an invasive test like cystoscopy in a young
person should only be made after some other initial tests, and in
some cases probably does not need to be done at all. As you suggest,
one initial branch point is glomerular versus nonglomerular blood.
It is extremely unlikely that an Ob/Gyn will feel competent looking
at a urine and making that distinction. (You may understand this, but
from your post it's not clear that you do: by definition, glomerular
blood is coming from some sort of process inside the kidneys -- the
glomeruli are the main filtering mechanism of the kidneys.)
If there is only a small amount of blood on spun urine (presumably
the more detailed test mentioned above) some doctors would feel
comfortable ignorning it all together. (Small amount would be less
than 5 or 6 RBCs per high powered field.) Also, there may be
historical factors to explain hematuria. Runners often have small
amounts of hematuria.
If the blood on spun urine appears to be glomerular than there
is a kidney issue (which may or may not require further evaluation)
but certainly does not require cystoscopy. If the blood does not
seem to be glomerular, some doctors would perform a radiologic test
with dye (either a CT scan or an IVP) and send urine for cytology and
if these are negative stop at that point.
In general, this is actually a common problem with a complex list
of causes, and the workup is often not handled all that sensibly.
It is far too complex to give extensive information about on the
net -- if possible it may be worth seeing an experienced general
internist or even a nephrologist to see if an invasive workup
(like cystoscopy) makes sense.
-- David Rind drind@caregroup.harvard.edu
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