Should patients on anticoagulant therapy with haematuria be investigated immediately?
Date First Published:
July 6, 2005
Last Updated:
July 15, 2005
Report by:
Philippa McCaffrey, 4th Year Medical Student (Manchester Royal Infirmary)
Search checked by:
Philippa McCaffrey, Manchester Royal Infirmary
Three-Part Question:
In [adults with asymptomatic haematuria on anticoagulats] is [immediate GUS investigation better than delayed investigation or no investigation at all] at [detecting significant underlying pathology]?
Clinical Scenario:
A 71 year old lady on warfarin for her atrial fibrillation presents to the Emergency Department with blood in her urine. You know that warfarin increases the chance of bleeding but wonder if urological investigation might reveal a significant pathologic finding.
Search Strategy:
Medline using the OVID interface - 1966 to June Week 1 2005
Embase - 1980 to 2005 Week 24
CINAHL - 1982 to June Week 1 2005
Cochrane Library - Issue 2 2005
Embase - 1980 to 2005 Week 24
CINAHL - 1982 to June Week 1 2005
Cochrane Library - Issue 2 2005
Search Details:
(exp. HEMATURIA OR haematuria.mp) AND (ANTICOAGULA$.mp. OR exp. ANTICOAGULANTS)
Limit to (Humans, English Language, Adults (19 and over))
Limit to (Humans, English Language, Adults (19 and over))
Outcome:
Medline - 221 papers found of which 4 were relevant
Embase - no additional relevant papers
CINAHL - no additional relevant papers
Cochrane Library - no additional relevant papers
1 additional paper found by a manual search of references
Embase - no additional relevant papers
CINAHL - no additional relevant papers
Cochrane Library - no additional relevant papers
1 additional paper found by a manual search of references
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Clinical significance of gross hematuria and its evaluation in patients receiving anticoagulant and aspirin treatment Avidor Y, Nadu A, Matzkin H 2000 Israel | All patients admitted due to gross haematuria while receiving warfarin or aspirin treatment between 1990 and 1998. 76 men and 17 women. Average age 76. | Retrospective cohort study | Results of evaluations in patients presenting with gross haematuria | Significant urologic pathologic finding in 69 patients (74%) including 22 (24%) previously unknown malignant tumours of the urinary tract | Only incledes gross haematuria. |
| Anticoagulant associated hematuria: a prospective study Van Savage JG, Fried FA 1995 USA | 32 consecutive patients with new onset of gross or microscopic haematuria while on anticoagulant therapy. 30 of these patients were evaluated | Prospective cohort study | Significant urinary tract disease found | 9 (30%) of which 6 were symptomatic and 3 were asymptomatic | Not all patients received identical work up. 20 patients had symptoms referrable to the GU tract. |
| Clinical significance of hematuria in patients on anticoagulant therapy Schuster GA, Lewis GA 1987 | 29 consecutive patients in whom gross or microscopic haematuria developed while they were on heparin or warfarin anticoagulant therapy | Prospective cohort study | Significant underlying pathology causing haematuria detected | 17/29 (58.6%) | Full paper not available. Abstract used. |
| Insignificant lesions causing haematuria detected | 6/29 (20.7%) | ||||
| The significance of hematuria in the anticoagulated patient Culclasure TF, Bray VJ, Hasbargen JA 1994 USA | Patients receiving long-term anticoagulation and controls not receiving such therapy monitored with monthly urinalysis. Patients who developed haematuria further studied for genitourinary tract diseae | Prospective cohort study | Number of subjects where genitourinary tract disease was identified | 81% | Full paper not available. Abstract used. |
| Unexplained hematuria Barkin M, Lopatin W, Herschorn S, Comisarow R 1983 Canada | 270 consecutive patients who presented with haematuria over 12-month period undergoing urography and cystoscopy | Prospective study | Important underlying pathology causing haematuria found | 17% | Full paper not available. Abstract used. |
Author Commentary:
No evidence was found to answer the part of the question querying the timescale on which the investigations should be carried out. However, a conclusion can be drawn from the data found.
Bottom Line:
Adult patients on anticoagulant therapy presenting to the Emergency Department with haematuria require complete genitourinary system investigation.
References:
- Avidor Y, Nadu A, Matzkin H. Clinical significance of gross hematuria and its evaluation in patients receiving anticoagulant and aspirin treatment
- Van Savage JG, Fried FA. Anticoagulant associated hematuria: a prospective study
- Schuster GA, Lewis GA. Clinical significance of hematuria in patients on anticoagulant therapy
- Culclasure TF, Bray VJ, Hasbargen JA. The significance of hematuria in the anticoagulated patient
- Barkin M, Lopatin W, Herschorn S, Comisarow R. Unexplained hematuria