In younger adults with haematuria is it more appropriate to refer to a urologist or a nephrologist?
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 under the age of 50 with haematuria] is [referral to a nephrologists better than referral to a urologist] at [detecting significant underlying pathology in a timely and cost effective manner]?
Clinical Scenario:
A 44 year old man presents to the Emergency Department with a week long history of blood in his urine. You wonder if this patient would be more appropriately referred to a nephrologist or a urologist since you are aware that there are many causes of haematuria and that in a younger person a lot of them are not surgically defined urological problems.
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 ((REFERRAL.mp. or exp. "Referral and Consulation"/) OR (urolog$.mp. OR exp. Urology/ or UROLOGIST.mp.) OR (NEPHROLOG$.mp. OR exp. Nephrology/ or NEPHROLOGIST.mp.))
Limit to (Humans, English Language, Adults (19 and over))
Limit to (Humans, English Language, Adults (19 and over))
Outcome:
Medline - 562 papers found of which 3 were relevant
Embase - no additional relevant papers
CINAHL - no additional relevant papers
Cochrane Library - no additional relevant papers
Embase - no additional relevant papers
CINAHL - no additional relevant papers
Cochrane Library - no additional relevant papers
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Glomerular disease as a cause of isolated microscopic haematuria Topham PS, Harper SJ, Furness PN, Harris kpg, Walls J, Feehally J 1994 UK | All patients (165) referred with isolated microscopic haematuria between Jan 1984 and Dec 1991. 94 male and 71 female. All undergoing renal biopsy and cystourethroscopy. Mean age was 37.5 (range 10-71). 135/165 (81.2%) of subjects under 50 years of age. | Prospective cohort study | Renal pathology detected | 77/165 (46.6%) | Referral bias. 17% had already had urological investigation including cystoscopy which might result in a low perceived incidence of urological abnormalities. No clear indication of what proportion of which pathologies were in which age group. Subjects under 18 years of age included. Gross haematuria not included. |
| % of patients under 45 years of age with normal cystoscopy | 100% | ||||
| Urological pathology detected | 5/165 (3%) of which 2 also had IgA nephropathy | ||||
| % of renal biopsy abnormalities in subjects older than 50 years | 41% | ||||
| % of renal biopsy abnormalities in subjects younger than 50 years | 53.50% | ||||
| Significance of the evaluation of asymptomatic microscopic haematuria in young men Sparwasser C, Cimniak HU, Treiber U, Pust RA 1994 Germany | 157 men (mean age 24.8 years, age range 19-35) presenting with asymptomatic haematuria between Jan 1989 and Dec 1991 | Prospective study | Patients discovered to have urological disease | 23 (14.6%) | Gross haematuria not included. Only men included. 24 patients withdrew before IVU, 10 rejected cystourethroscopy, 18 did not consent to renal biopsy therefore 57/157 (33.1%) not evaluated properly. Sample not comparable to the general population as all were military personnel. |
| Patients discovered to have glomerulopathy | 26 (16.5%) | ||||
| Significance of microhaematuria in young adults Froom P, Ribak J, Benbassat J 1984 Israel | 1000 asymptomatic male air force personnel examined for the results of 15 yearly examinations of urinary sediment. Period covered 1968-82 beginning with subjects aged 18-33 years | Retrospective cohort study | Incidence of urological pathology at 15 years | 0.1% TCC | Sample not representative of general population - all male, all military personnel. |
| Incidence of nephrological pathology at 15 years | 0.6% Urolithiasis | ||||
| 0.1% Vesical calculi | |||||
| 0.10% |
Author Commentary:
Lack of good quality specific evidence makes a definitive clinical bottom line difficult to reach. However, the evidence shows a similar incidence of nephrological and urological pathology in this group of patients.
Bottom Line:
Patients under 40 years of age presenting to the Emergency Department with haematuria are equally appropriately referred to a urologist or a nephrologist for further investigation.
References:
- Topham PS, Harper SJ, Furness PN, Harris kpg, Walls J, Feehally J. Glomerular disease as a cause of isolated microscopic haematuria
- Sparwasser C, Cimniak HU, Treiber U, Pust RA. Significance of the evaluation of asymptomatic microscopic haematuria in young men
- Froom P, Ribak J, Benbassat J. Significance of microhaematuria in young adults