microscopic hematuria testing & questions

googleuser1968 said:

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 [email hidden]