Differential Diagnosis for Urinary Pain, Gross Hematuria, and Microscopic Hematuria with Leukocytes
Single Most Likely Diagnosis
- Urinary Tract Infection (UTI): The presence of urinary pain, gross hematuria followed by microscopic hematuria, and significant leukocytes (3+) in the urine strongly suggests a UTI. The negative nitrites do not rule out this diagnosis, as not all bacteria that cause UTIs produce nitrate reductase, an enzyme that converts nitrate to nitrite.
Other Likely Diagnoses
- Kidney Stones (Nephrolithiasis): The initial presentation of gross hematuria and subsequent microscopic hematuria, along with urinary pain, could be indicative of a kidney stone. The presence of leukocytes might suggest an associated infection.
- Interstitial Cystitis: This condition can cause urinary pain and sometimes hematuria, although it is less commonly associated with significant leukocyturia.
Do Not Miss Diagnoses
- Bladder Cancer: Although less likely, bladder cancer can present with painless gross hematuria. The presence of leukocytes and urinary pain might distract from this diagnosis, but it is crucial to consider, especially in older adults or those with risk factors like smoking.
- Tuberculosis (TB) of the Urinary Tract: TB can cause hematuria, leukocyturia, and urinary symptoms. It is essential to consider this diagnosis, especially in endemic areas or in individuals with a history of TB exposure.
Rare Diagnoses
- Sickle Cell Disease or Sickle Cell Trait: These conditions can cause hematuria due to sickling in the hypoxic environment of the kidney medulla. While less common, they should be considered, especially in individuals of African descent.
- Goodpasture Syndrome: An autoimmune disease that can cause glomerulonephritis and pulmonary hemorrhage, presenting with hematuria. It is rare but critical to diagnose due to its potential for severe outcomes.
- Schistosomiasis: In endemic areas, this parasitic infection can cause urinary symptoms, including hematuria and leukocyturia, due to the eggs of the parasite causing inflammation in the bladder wall.