From the Guidelines
The workup for a patient with hematuria, proteinuria, and back pain should begin with a referral to a nephrologist for evaluation of medical renal disease, as well as a risk-based urologic evaluation to identify coexistent urologic pathology. This approach is recommended because patients with proteinuria, dysmorphic RBCs, cellular casts, or renal insufficiency may have medical renal disease, which can cause hematuria 1. The initial evaluation should include a comprehensive history and physical examination, followed by laboratory and imaging studies to identify the underlying cause.
- Initial laboratory tests should include:
- Urinalysis with microscopy to confirm hematuria and quantify proteinuria
- Complete blood count to assess for anemia or infection
- Comprehensive metabolic panel to evaluate kidney function (BUN, creatinine)
- Urine protein-to-creatinine ratio to quantify proteinuria
- Additional tests should include:
- Urine culture to rule out infection
- Serum complement levels (C3, C4) and autoimmune markers (ANA, ANCA, anti-GBM antibodies) if glomerulonephritis is suspected
- Imaging studies should start with a renal ultrasound to evaluate kidney structure, stones, or masses, followed by CT scan of the abdomen/pelvis with contrast if indicated to better visualize the kidneys, ureters, and bladder 1.
- For patients over 35 years or with risk factors for malignancy, cystoscopy may be necessary to evaluate for bladder cancer. This comprehensive approach is essential because this symptom triad can indicate various conditions ranging from urinary tract infections and kidney stones to more serious conditions like glomerulonephritis, polycystic kidney disease, or renal cell carcinoma, and the back pain component particularly raises concern for kidney stones, pyelonephritis, or renal masses that may be causing capsular distention.
From the Research
Workup for Hematuria, Proteinuria, and Back Pain
The workup for a patient with hematuria, proteinuria, and back pain involves a thorough history and physical examination to determine potential causes and assess risk factors for malignancy 2. The following steps are recommended:
- Laboratory tests to rule out intrinsic renal disease
- Imaging of the urinary tract
- Referral to nephrology and urology subspecialists 2
- Urine culture, urine calcium-to-creatinine ratio, and renal and bladder sonography may be required for gross or macroscopic hematuria 3
- A detailed evaluation for renal parenchymal disease, stones, tumors, or anatomic abnormalities may be necessary 3
Considerations for Benign Hematuria
For patients with benign hematuria, ureterorenoscopy has become an excellent means of diagnosing and treating lesions such as renal hemangiomas 4. The use of small, flexible ureteroscopes and various instruments like electrocautery probes, Nd:YAG laser, and Holmium:YAG laser has been effective in treating these lesions 4.
Importance of Renal Biopsy
Renal biopsy is important for patients with hematuria and/or proteinuria found during routine examination, as renal pathologic change does not always coincide with clinical manifestations 5. Early treatment and careful follow-up are helpful in these patients, and the renal outcome is associated with proteinuria and tubulointerstitial lesions 5.
Differential Diagnoses for Flank Pain and Hematuria
Flank pain and hematuria can have differentials beyond nephrolithiasis, such as Page kidney, which describes compression of the renal parenchyma by a hematoma or mass causing secondary hypertension 6. A thorough evaluation, including non-contrast CT and CTA, may be necessary to diagnose and manage these conditions 6.