From the Guidelines
The appropriate management for a patient with hematuria and leukocytes in the urine should start with a thorough history, physical examination, urinalysis, and serologic testing, followed by urine culture and empiric antibiotic therapy if a urinary tract infection is suspected, as recommended by the American College of Radiology 1. The presence of blood and leukocytes in the urine suggests a possible urinary tract infection or inflammation, and the initial step should be to determine the underlying cause.
- A urine culture should be obtained to confirm the presence of an infection and to guide antibiotic therapy.
- Empiric antibiotic therapy can be started with first-line antibiotics such as nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin, depending on the severity of the symptoms and the patient's medical history.
- Patients should increase fluid intake to help flush the urinary system, and urinary analgesia with phenazopyridine can be provided for up to 2 days if symptoms are severe. Beyond infection management, further investigation may be necessary, including:
- Imaging studies such as ultrasound or CT, especially for patients over 35 or those with risk factors for urological malignancies.
- Cystoscopy, particularly if hematuria persists after treating the infection or if there are suspicious findings on imaging studies. This comprehensive approach ensures that the immediate concern of possible infection is addressed while also considering the possibility of more serious underlying conditions, such as kidney stones, inflammatory disorders, or urological malignancies, as highlighted in the American College of Radiology's guidelines for hematuria 1.
From the Research
Management of Hematuria and Leukocytes in Urine
The presence of blood and leukocytes in urine can be an indication of a urinary tract infection (UTI) or other underlying conditions. The management of such patients requires careful evaluation and consideration of various factors.
- Urinalysis and Microscopic Examination: Studies have shown that urinalysis and microscopic examination may not be reliable screening tests for UTIs. For example, a study published in the American Journal of Clinical Pathology in 2000 found that the presence of leukocyte esterase, nitrite, and bacteria in the microscopic examination had a lack of sensitivity for detecting UTIs 2.
- Leukocyte Esterase Test: On the other hand, a study published in the Annals of Emergency Medicine in 1984 found that the leukocyte esterase test was 100% sensitive and 76% specific in predicting significant bacteriuria 3.
- Cutoff Values for Bacteria and Leukocytes: A study published in Diagnostic Microbiology and Infectious Disease in 2009 established cutoff values for bacteria and leukocytes using a urine flow cytometer. The study found that a cutoff value of 40 white blood cells/microL and 125 bacteria/microL could be used to indicate a UTI 4.
- Presence of UTI and Urologic Malignancy: A study published in Urologic Oncology in 2013 found that the presence of a culture-positive UTI did not exclude the possibility of urologic malignancy. In fact, 20% of patients with a positive mid-stream urine culture had a urologic malignancy diagnosed 5.
- Abnormal Urinalysis Results: A study published in The Journal of Emergency Medicine in 2015 found that abnormal urinalysis results were common in women without UTIs, regardless of specimen collection technique. This highlights the importance of interpreting urinalysis results in the context of clinical symptoms and other diagnostic tests 6.
Key Considerations
When managing a patient with hematuria and leukocytes in urine, it is essential to consider the following:
- A thorough medical history and physical examination should be performed to identify any underlying conditions that may be contributing to the symptoms.
- Urinalysis and microscopic examination should be interpreted with caution, and other diagnostic tests such as urine culture and imaging studies may be necessary to confirm the diagnosis.
- The presence of a UTI does not exclude the possibility of urologic malignancy, and further evaluation may be necessary to rule out other underlying conditions.