dense. May also reveal GI abnormality. 4. Special studies. Cystogram, nuclear renal scan, and angiography are second-line studies that should be obtained only after urology or nephrology consultation.
V. Plan. Treatment depends on etiology. Cause of hematuria is rarely an emergency except for gross hematuria (with or without clots), for which the cause could be trauma, severe coagulation abnormality, or cyclophosphamide-induced cystitis.
A. UTI. Begin treatment before culture results are known if patient is ill with symptoms and there are > 10 WBCs/HPF (infection is very likely) or if evidence of sepsis or pyelonephritis is present (increased C-reactive protein, ESR, high WBC count with left shift).
B. Urolithiasis. Stones < 5 mm are usually passed by patient (manage with hydration and analgesics). Obtain urology consultation if stones are large or associated with obstruction or infections.
C. Obstruction or Other Urologic Abnormalities. Consult urology colleagues; arrange nephrology consultation if renal impairment is present.
D. Neoplasm. Consult oncology, urology, or surgery colleagues.
E. Glomerulonephritis. Obtain nephrology consultation for consideration of renal biopsy, further evaluation, and treatment.
F. Coagulopathy. Attempt to correct the clotting abnormality, and consult hematology colleagues.
G. Hemorrhagic Cystitis. Consult urology colleagues. Treatment of a patient with hemorrhagic cystitis consists of saline irrigation, but primary treatment is prevention with hydration and mesna.
VI. Problem Case Diagnosis. The 10-year-old patient had hemorrhagic cystitis. On further investigation, the inciting agent for the bladder injury was found to be cyclophosphamide therapy.
VII. Teaching Pearl: Question. What are clues that a UTI involves the kidney (upper tract infection)?
VIII. Teaching Pearl: Answer. Flank or back pain, vomiting, elevated C-reactive protein, WBC or RBC casts, loss of urine concentrating ability, abnormal DMSA scan.
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