History of Present Illness

A 30-year-old female, gravida 1, para 1, presents to your clinic for a six-week postpartum visit following a vaginal delivery. After asking how she is doing, she awkwardly admits to having issues with unintentional loss of gas.

She passes flatus without intending to on a frequent basis, and experienced an episode of accidental bowel leakage that stained her underwear when she had loose stools. She denies loss of urine, pelvic pain, or constipation, but does have urgency prior to defecating, which causes her to rush to the bathroom. She very rarely has diarrhea. These issues are making her anxious to go out in public and cause significant embarrassment. She had a third-degree perineal laceration during the birth of her child.

She is otherwise healthy and has had no surgeries. She takes no medications. She has no allergies. She does not smoke, drink alcohol, or use other substances or drugs.

Physical Examination

General appearance

Well-developed, well-nourished woman, appearing anxious

Pulse

74 beats/min

Blood pressure

122/64 mmHg

Respiratory rate

12 breaths/min

Height

63 inches

Weight

140 lb

BMI

24.8 kg/m²

Abdomen

Soft, non-tender, non-distended. No rebound or guarding

External genitalia

Normal-appearing labia majora and minora bilaterally. Well-healed perineal laceration with no discharge or erythema

Vagina

Pink, rugated with no bleeding or discharge.

Cervix

Normal-appearing parous cervix, closed with no active bleeding or discharge

Rectal examination

Mildly decreased external sphincter tone, no stool in rectal vault. Perianal reflexes with positive anal wink.

Labs/Imaging

None

How Would You Manage This Patient?

The patient has postpartum flatal incontinence and had fecal incontinence with diarrhea after a vaginal delivery that was complicated by external anal sphincter injury from a third-degree perineal laceration. Initial recommendations included dietary changes targeted at minimizing episodes of urgency and diarrhea, which were contributing to her symptoms. The patient kept a food diary that identified dietary irritants, ate small, frequent meals, started stool-bulking agents, and treated her rare diarrhea with Loperamide. She was also referred to pelvic floor physical therapy. She returned to clinic two months later noting no further episodes of fecal incontinence and rare flatal incontinence.

Postpartum Flatal and Fecal Incontinence

Anal incontinence is the term encompassing both flatal and fecal incontinence. Flatal incontinence is the involuntary loss of gas, and affects approximately one in four women in the postpartum period. Fecal incontinence often presents with loss of liquid stool and occurs in about one in ten women postpartum [1]. Though extremely common, anal incontinence is more of a taboo subject than urinary incontinence, and patients rarely bring up this issue to providers without being directly asked. The problem frequently is undiagnosed and can be profoundly distressing to a patient. If symptoms persist, it can negatively impact quality of life, social activities, and emotional health, and cause difficulty in sexual relationships that can last for years [1]. Fecal incontinence has greater impact than flatal incontinence alone [2].

The etiology of anal incontinence is complex, as continence is achieved by multiple methods. The increased burden of pregnancy on the pelvic floor can cause anal incontinence, with many women complaining of involuntary loss of gas and stool prior to delivery. Up to one-third of women describe flatal or fecal loss during the last four weeks of pregnancy [1]. This prenatal anal incontinence, which is thought to be caused by nerve damage, is highly predictive of postpartum incontinence. No interventions have been successful for prevention. Labor and delivery events are important, with a number of identifiable risk factors for later anal incontinence (Box 80.1). Vaginal delivery with disruption of pelvic floor support and damage to the external anal sphincter is a major cause of flatal and fecal incontinence (Figure 80.1). Obstetric anal sphincter injuries (OASIS) with vaginal delivery are a risk factor for anal incontinence, with the highest rates of anal incontinence occurring in woman with OASIS, although not all women with OASIS experience such symptoms [4]. Twenty-seven percent of primiparous women have anal sphincter defects on endoanal ultrasound, but only 29 percent of these patients are symptomatic [5]. Because of damage to the pelvic floor prior to delivery, cesarean does not completely protect against anal incontinence. Seven percent of women continue to experience fecal incontinence at six months after cesarean delivery, with 4.5 percent of women persistently having accidental bowel leakage 3–5 years after delivery [1, 6]. Changes in transit of stool through the terminal rectum and anus due to diarrhea or constipation can exacerbate the dysfunction from the structural damage and lead to loss of gas or stool. A 2010 Cochrane review does not support elective cesarean delivery to prevent anal incontinence [7].

Figure 80.1 Pelvic bones and muscles of pelvic floor. Anatomic structures are indicated.

(Illustration by Joseph Werkmeister)

The diagnosis is usually made based on history and physical examination. Laboratory studies are not typically helpful and imaging rarely adds to the diagnosis or initial management. History should determine if the incontinence is fecal or flatal and should determine inciting causes. The term “accidental bowel leakage” is recommended as it tends to be more acceptable to patients and may increase the number of women who admit to the problem. Loss of solid versus liquid stool is helpful in estimating the degree of pelvic floor dysfunction, as loss of solid stool indicates more damage to the mechanisms of continence. Timing of symptoms, urgency, constipation, diarrhea, inciting medications, and underlying gastrointestinal conditions should be elicited. If the patient reports a history of chronic diarrhea, screening for underlying inflammatory bowel disease, irritable bowel syndrome, Celiac disease, lactose intolerance, and infectious causes may be indicated. Physical exam should target the pelvic floor. If the patient sustained a recent perineal laceration, the vaginal mucosa and perineal body should be inspected to ensure they are healing appropriately. The anal wink or anocutaneous reflex can be tested by stroking the skin surrounding the anus with a Q-tip, which should cause contraction of the external anal sphincter. Absence of this reflex indicates damage to the afferent or efferent nerves of S2-4 spinal arc. Rectal exam should be performed to determine the tone of the external anal sphincter, and presence of hemorrhoids or impacted stool. If examination is consistent with complete breakdown of the perianal body, rectal prolapse, or rectal exam concerning for malignancy, referral to a specialist is indicated.

Initial treatment for anal incontinence targets avoiding the identified inciting triggers for flatal and fecal loss. In women with fecal urgency as primary symptoms, small meals and stool bulking with powder-based supplementation can lead to symptomatic improvement. Methylcellulose 1–2 g in 8 oz of water daily or psyllium 1 capful (3.4 g in 8 oz of water) is a safe and effective option. The patient can maintain a food diary to identify and avoid triggers such as artificial sweeteners, lactose, fatty foods, gluten, spicy food, alcohol, or caffeine. This diary should also include episodes of both flatal and fecal loss, stool consistency, and symptoms of fecal urgency. Medications to slow colonic transit time, such as Loperamide 2 mg daily until stools are more formed, can be used sparingly when diarrhea is the trigger as long as there is low concern for underlying medical conditions that suggest referral to a specialist is warranted. We typically recommend using Loperamide 2 mg two to three times per week for at most 1–2 months and then slowly discontinue. Referral to pelvic floor physical therapy is beneficial for the entire pelvic floor and is recommended for initial therapy in women with low external anal sphincter tone and second-line therapy for those with a normal rectal tone. The goal of the therapy is to target both fast and slow twitch muscle fibers and contract the genital hiatus in order to stimulate pudendal nerve function. A Cochrane review suggests that some elements of biofeedback therapy and sphincter exercises may have a therapeutic effect, though data are limited [7]. Generally, symptoms will improve within 6–12 months with interventions. A long-term study with 12-year follow-up demonstrated lower rates of fecal incontinence one year after delivery with pelvic floor physical therapy. However, 43 percent of women who reported fecal incontinence three months postpartum still had symptoms 12 years after delivery and the benefit of physical therapy was not seen at that time [8]. Improvement and long-term continence are unpredictable.

This patient had vast improvement in her symptoms with conservative first-line management. If anal incontinence persists or worsens despite initial interventions, she could be referred to a specialist in Female Pelvic Medicine and Reconstructive Surgery or a colorectal specialist for further evaluation and management. Diagnostic studies can include anoscopy, defecography, anorectal manometry, pelvic and endoanal ultrasound, or colonoscopy, depending on the constellation of symptoms. Anal plugs, vaginal inserts, and scheduled bowel retraining have also been used for persistent anal incontinence, but adherence to these methods is poor overall or not well described in the literature. For persistent or severe anal incontinence, anal sphincteroplasty, injectable bulking agents, surgical placement of slings around the rectum, or sacral nerve stimulation can be used. Surgical outcomes are not well described, but generally lack long-term success [7]. Biofeedback and pelvic floor exercises as well as sacral nerve root implants demonstrate improvement in short-term symptoms, but long-term data are lacking as well [9].

If symptoms of anal incontinence are persistent at the time of the next pregnancy, many women and providers consider cesarean delivery, as the symptoms can worsen with subsequent vaginal deliveries. If anal sphincter injury occurred during the first pregnancy, the risk of repeat anal sphincter injury and long-term anal incontinence increases [6, 10]. Many women with persistent, severe incontinence opt for elective cesarean delivery in hopes to prevent long-term symptoms [6]. Currently, no recommendation regarding the route of delivery for women with history of incontinence after first delivery or continued symptoms has been universally accepted, so there should be a discussion and shared decision making between the patient and the provider.

Key Teaching Points

• 
  

  Using the term “accidental bowel leakage” may be more acceptable for patients and encourage more honest discussion of symptoms.

  
  
• 
  

  Flatal and fecal incontinence are extremely common after both vaginal and cesarean deliveries and typically improve over time.

  
  
• 
  

  Initial office management should include a comprehensive examination, but no imaging studies.

  
  
• 
  

  First-line medical management includes fiber supplementation for stool bulking, identifying dietary triggers, and pelvic floor physical therapy.

  
  
• 
  

  Cesarean is not recommended for primary avoidance of anal incontinence, but can be considered for subsequent deliveries for patients with severe, persistent symptoms.

History of Present Illness

A 46-year-old female, gravida 3, para 3, presents with complaint of leaking urine. The leakage began four years ago and has been increasing in frequency. She leaks 2–3 times daily, triggered by lifting, laughing, and sneezing. She changes protective undergarments 2–3 times per day. She is upset by these symptoms, concerned about malodor, and bothered by leakage at work and home. She reports no dysuria, continuous leakage, nocturia, slow stream, straining, or post-void leakage. She denies recurrent urinary tract infections or pelvic surgery. She does not experience involuntary passage of flatus or stool.

Her history is significant for three term vaginal births. Menses are regular. She is sexually active with one male partner, without sexual concerns, and has an IUD for birth control. She reports no diabetes, neurological disorders, or vascular disease. She is a nonsmoker and takes no prescription medications.

Physical Examination

General appearance

Alert, comfortable

Pulse

82 beats/min

Blood pressure

130/78 mmHg

BMI

31 kg/m²

Abdomen

Non-tender, non-distended, no palpable mass

External genitalia

Normal, no atrophy

Urethra

No diverticulum or mass

Vagina

Anterior vaginal wall prolapse with straining, leading edge 2 cm above the hymen (POP-Q Stage I)

Cervix

Normal

Uterus

Small, anteverted

Supine cough stress test

Leak of urine and urethral mobility observed simultaneous with cough

Voided volume

270 mL

Post-void residual urine volume (PVR)

40 mL

Urinalysis

Negative

Urine culture

No growth

How Would You Manage This Patient?

This patient has uncomplicated stress urinary incontinence (SUI). She is having the classic symptom, involuntary leakage of urine from the urethra simultaneous with effort and sneezing. Positive cough stress test, negative urinalysis, normal post-void residual, absence of pelvic organ prolapse beyond the hymen, and absence of other bladder storage and voiding symptoms confirm the diagnosis. Urodynamic testing is not necessary before initiating treatment. Therapy should be directed at alleviating bothersome symptoms and improving quality of life. The patient is a candidate for conservative therapies with behavioral and lifestyle modification, pelvic floor muscle exercises with or without pelvic floor physical therapy, and an incontinence pessary. With appropriate counseling, she may opt for primary surgical management.

The patient was counseled thoroughly about the likelihood of symptom control with various treatments and the risks and benefits of each, including surgery. She wished to reduce incontinence episodes but preferred to avoid surgery. The patient was instructed to reduce caffeine intake, avoid constipation, perform pelvic floor muscle (Kegel) exercises, and keep a voiding diary to determine if leakage was more likely to occur at higher bladder volumes. She was advised of the benefits of moderate weight loss to reduce incontinence episodes for obese women and agreed to increase physical activity and manage her diet. She was provided written information about pessaries and surgical management. She returned in eight weeks for follow-up. She reported improvement in her symptoms to the point that they were tolerable and not interfering with her daily activities. She was counseled that her symptoms may worsen with age and additional treatment could be initiated as necessary. Her symptoms will be reviewed at her periodic well-woman visits.

Stress Urinary Incontinence

SUI occurs when urine involuntarily leaks from the urethra simultaneous with effort, physical exertion, sneezing, or coughing. Overall, incontinence affects 44–57 percent of adult women in the United States, up to 75 percent of US female nursing home residents, and millions of women worldwide [1, 2]. Prevalence increases with older age, higher body mass index, increasing parity, postmenopausal status, and medical conditions such as neurologic disease or poorly controlled diabetes. This patient was at risk for SUI given her age and obesity. Urgency and mixed (coexisting stress and urgency) incontinence are also common. The differential diagnosis also includes extra-urethral incontinence from fistulas or ectopic ureter, functional incontinence due to cognitive or mobility impairment, incontinence from chronic urinary retention (“overflow”), postural, coital, and occult (revealed after reduction of prolapse). Establishing the correct diagnosis is important since prognosis and treatment options vary considerably.

This patient sought care due to distress at work and home. Urinary incontinence often has a negative impact on quality of life and can be debilitating. Many women avoid seeking care due to stigma and other barriers, so providers should screen for incontinence at periodic well-woman visits [1]. Questionnaires to assess distress and symptom severity can be administered at the first visit and serially to define goals and monitor response to therapy. Several validated tools are available, including the Urogenital Distress Inventory and Incontinence Impact Questionnaire (IIQ) [1, 3].

History should include duration of symptoms, frequency, precipitating factors, protective pad use, and fluid intake. Leakage occurring only with increased intra-abdominal pressure is consistent with SUI. However, leakage immediately preceded or accompanied by a strong urge to void is concerning for urge incontinence and leakage without provocation is concerning for fistula. Bladder storage (urgency, incomplete bladder emptying, and continuous leakage) and voiding symptoms (hesitancy, slow stream, intermittency, straining, spraying, need to re-void, postmicturition leakage, position-dependent micturition, and dysuria) should be assessed to determine whether SUI is complicated [3, 4]. Complicated SUI is also diagnosed when history of any of the following is identified: previous incontinence surgery, complex urethral surgery, radical pelvic surgery, prior pelvic radiation therapy, recurrent UTIs, poorly controlled diabetes, neurological disease, or dementia. This patient had no such history and no additional storage or voiding symptoms, consistent with uncomplicated SUI.

Physical examination should be performed to characterize any abdominal or pelvic masses, urethral abnormalities (such as mass or diverticulum), vulvovaginal atrophy, or fistula. The International Federation of Gynecology and Obstetrics (FIGO) recommends that pelvic organ prolapse be assessed using either the POP-Q or, in practice settings where complexity of POP-Q is prohibitive, the simplified version S-POP [5, 2]. In addition, a minimum of four additional assessments should be performed [1, 3, 2]:

1. 
   

   (1) Cough stress test

   
   
2. 
   

   (2) Assessment of urethral mobility

   
   
3. 
   

   (3) Urinalysis or dipstick

   
   
4. 
   

   (4) Measurement of post-void residual urine volume (PVR)

When feasible, many clinicians instruct patients to arrive with a comfortably full bladder to facilitate evaluation. Cough stress test and urethral mobility evaluation are first performed during supine pelvic examination. While the urethral meatus is visualized, the patient is instructed to relax, then cough. Urinary leakage and excessive downward urethral displacement simultaneous with cough are consistent with SUI. When the cough stress test is negative, it should be repeated with the patient standing and with a full bladder. To be valid, there must be adequate urine volume at the time of the test. Bladder volume can be evaluated with a bladder scanner to ensure at least 300 mL of urine is present or the bladder can be backfilled under sterile conditions to a minimum of 300 mL before the test is repeated. The cotton swab test is traditionally used to evaluate for urethral hypermobility. A lubricated cotton swab is inserted through the urethra to the bladder neck and displacement >30 degrees from horizontal with Valsalva is considered hypermobile. Measurement of POP-Q point Aa, while important in the evaluation of prolapse, is not recommended by FIGO as a test for urethral hypermobility [2]. Urine dipstick or urinalysis should be performed to rule out infection and significant hematuria. PVR should be assessed either with a bladder scanner or sterile catheter immediately after voiding. Though controversy exists, FIGO and ACOG agree that PVR <150 mL is normal. Complicated SUI is diagnosed when office evaluation reveals pelvic organ prolapse beyond the hymen, genitourinary fistula, urethral diverticulum, absence of urethral mobility, or PVR>150 mL.

For uncomplicated SUI, as was diagnosed in this case, urodynamic testing is not indicated prior to management [3, 2]. In cases where the diagnosis remains unclear after thorough office examination or SUI is complicated, for example by advanced prolapse beyond the hymen, prior incontinence surgery, or pelvic radiation therapy [1, 3], urodynamic testing or specialist referral (where available) is advised.

A simple bladder diary recorded by the patient for 1–3 days should be recommended after the initial office visit and provides information about frequency of leakage episodes, related fluid intake, and precipitating factors. This information assists in confirming the diagnosis, initiating lifestyle modifications, and monitoring response to treatment. A free online version is available for download (see www.niddk.nih.gov/health-information/health-topics/urologic-disease/daily-bladder-diary/Documents/diary_508.pdf).

Currently, there is no effective pharmacologic therapy for SUI. All patients are candidates for conservative management with lifestyle modifications, pelvic floor (Kegel) exercises, and behavioral therapy. Obese women have a fourfold higher risk for SUI compared with normal weight women. Obese women assigned to an intensive weight-loss program reduced the frequency of incontinence episodes by 70 percent or more compared with controls [6], so weight loss should be advised when indicated. Observational studies demonstrate that caffeine intake, constipation, and carbonated beverage consumption are each independently associated with incontinence episodes, so reducing or eliminating these triggers may be of benefit [1]. Women with excessive (>2 L) daily fluid intake, leakage at higher bladder volumes, or nocturia identified on the bladder diary can be advised to limit fluid intake to 2 L daily, time voids (see bladder training below), or decrease fluid intake before bedtime. Pelvic floor muscle (Kegel) exercises are commonly recommended with or without pelvic floor physical therapy or biofeedback to strengthen voluntary muscles of the pelvic floor. An online video series is available to teach techniques: www.nrsg101.com/kegel-exercise.html. Instructions are also available through the National Association for Continence: www.nafc.org/kegel. Regardless of regimen, pelvic floor muscle training alone or in combination with other therapies is effective for reducing incontinence episodes, improving quality of life, and restoring continence with 50 percent satisfaction at one year [1]. Behavioral therapy with bladder training employs a fixed voiding schedule with progressively increasing time between voids. A 2004 Cochrane review [7] concluded that bladder training may be considered first-line therapy for stress, urge, and mixed incontinence with a 50 percent reduction in mean incontinence episodes. Instructions for patients and providers are available through the National Association for Continence: www.nafc.org/bladder-retraining. Response to conservative management can be evaluated longitudinally using a voiding diary or validated tools such as the Patient Global Impression of Improvement and Patient Global Impression of Severity measures [8]. This patient preferred conservative treatment and, at least over the short term, was satisfied with her improvement. Close follow-up is important since incontinence symptoms may vary over time, with approximately 50 percent of women in conservative management crossing over to surgery within one year [1].

Patients with SUI with or without prolapse can be offered a pessary trial [1], which this patient initially declined. Patients who fail conservative therapy, desire future fertility, and wish to avoid or delay surgery are good candidates. Incontinence pessaries support the proximal urethra and bladder neck to increase urethral resistance (Figure 81.1) and often contain a knob for anterior positioning under the urethra, though many shapes and sizes exist. Pessaries should be fitted by a trained clinician. Undue pressure from a large pessary creates risk for vaginal erosion or urinary obstruction, while a pessary that is too small will be ineffective.

Figure 81.1 Woman’s pelvis with vagina, bladder, and pessary.

National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health

Surgery can be considered first-line treatment for patients who have completed thorough office evaluation, have uncomplicated SUI, decline conservative management or pessary, are medically cleared for surgery, and are appropriately counseled about the risks, benefits, and outcomes of surgical management. A 2009 Cochrane review of surgeries for uncomplicated SUI concluded that pubovaginal slings (Figure 81.2), Burch colposuspension, and mid-urethral slings were equally effective [9]. Synthetic mid-urethral slings are also highly effective [10] and are currently the most commonly performed incontinence procedures given reduced operative time and shorter recovery. Long-term effectiveness and safety of the transobturator (TOT) and retropubic (TVT) mid-urethral approaches are similar [11].

Figure 81.2 Side view of female bladder supported by a sling to prevent urinary incontinence. The sling is wrapped around the urethra, and the ends are attached to the pubic bone. Labels point to the bladder, bladder neck, pubic bone, sling material, and urethra.

National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health

Key Teaching Points

• 
  

  The classic symptom of SUI is involuntary urine leakage from the urethra simultaneous with physical exertion or effort, coughing, or sneezing.

  
  
• 
  

  In addition to history and physical examination, minimum initial office evaluation for women with incontinence includes urinalysis or dipstick, cough stress test, assessment of urethral mobility, and measurement of PVR.

  
  
• 
  

  If the initial supine cough stress test is negative, the test should be repeated with the patient standing and with a full bladder.

  
  
• 
  

  For women with uncomplicated SUI, urodynamic testing is not indicated prior to therapy. In cases where the diagnosis is unclear or SUI is complicated, urodynamic testing or specialist referral is recommended.

  
  
• 
  

  Management options include lifestyle modifications, pelvic floor (Kegel) exercises, behavioral therapy, and incontinence pessaries. Appropriately counseled patients may opt for primary surgical management.

History of Present Illness

A 48-year-old woman, gravida 3 para 3, presents to the office for an annual exam. She states that two months ago she had a urinary tract infection that was diagnosed by her primary care physician. Her physician told her she had “some blood in her urine.” She reports that she gets urinary tract infections frequently, about three times per year. She would like a test today to ensure that the blood has resolved. She denies dysuria, flank pain, abdominal pain, gross hematuria, or vaginal bleeding. Her last menstrual period was two weeks ago.

Her past medical history is significant for hypothyroidism. Her past surgical history is negative. She reports no history of STDs or abnormal pap tests. She had three full-term vaginal deliveries followed by a tubal ligation. She is an avid runner, completing her first half marathon last month, and denies tobacco use, alcohol, or drugs. She is sexually active with her husband and lives with him and her three children. She works as a lawyer.

Physical Examination

General appearance

Well-developed, well-nourished in no distress

BP

110/70 mmHg

Weight

130 lb

Height

65 inches

BMI

21 kg/m²

Abdomen

Soft, non-tender, non-distended, no costo-vertebral angle tenderness

External genitalia

Normal vulva and urethra

Vagina/cervix

Normal, no blood

Uterus

Anteverted, small, mobile, non-tender

Adnexa

Non-tender, no masses

Urinalysis (dipstick):

Leukocytes

Negative

Nitrite

Negative

Urobilinogen

Negative

Protein

Negative

pH

6.5

Blood

1+ (small)

Specific gravity

1.005

Ketones

Negative

Bilirubin

Negative

Glucose

Negative

Urine culture (from two months prior)

No growth

How Would You Manage This Patient?

The patient has evidence of blood on a urine dipstick test. She does not report symptoms of a urinary tract infection currently, and had a negative culture from her visit with her PCP two months prior. She does not report any symptoms that suggest a urinary stone as a cause of the hematuria. While infection and stones are common causes of transient hematuria, in patients without evidence of those diagnoses, depending on the amount of blood, it may be important to investigate for other causes.

Evidence of blood on a urine dipstick necessitates evaluation with a formal urinalysis and microscopy. In a nonsmoking woman under age 50, further workup is only recommended if the microscopic evaluation reveals >25 RBCs per high-power field (hpf) [1].

The patient’s urinalysis and microscopic evaluation are as follows:

Color

Yellow

Appearance

Clear

Specific gravity

1.020

pH

7.0

Protein

Negative

Glucose

Negative

Blood

Moderate (2+)

Ketones

Negative

Bilirubin

Negative

Urobilinogen

<2.0 mg/dL

Nitrite

Negative

Leukocyte Esterase

Negative

WBCs

1/hpf

RBCs

40/hpf

Epithelial cells

<1/hpf

Casts

Negative

Given the presence of 40 RBCs/hpf, she was informed of the finding of microscopic hematuria. She had no evidence of glomerular disease on her urinalysis and a repeat urine culture was also negative. She was scheduled for imaging with a computerized tomography (CT) urogram and referred to urology for cystoscopy. No definitive cause of her microscopic hematuria was identified. A repeat urinalysis is planned in one year.

Microscopic Hematuria with a Negative Urine Culture

Unexplained hematuria is fairly common. Some studies have demonstrated asymptomatic microscopic hematuria in up to 40 percent of patients [2]. In patients under the age of 35, hematuria is usually transient and of no consequence. In nonsmoking women under 50, the risk of urinary tract malignancy is very low [1].

Microscopic hematuria is defined as the presence of three or more RBCs per hpf from a spun specimen in the absence of a color change to the urine. It is frequently identified incidentally when a urinalysis is ordered for another reason. While microscopic evaluation is the gold standard, urine dipsticks can reliably detect microscopic hematuria of 1–2 RBCs/HPF. Several contaminants can cause false positive urine dipsticks for hemoglobin including semen, agents used to clean the perineum, and myoglobinuria. Contamination with menstrual blood can also cause false positives on both dipstick and microscopic evaluation. If menstrual contamination is suspected, the test can be repeated after menses or after inserting a tampon prior to specimen collection. Because of the increased incidence of benign causes of hematuria in young women, and the low risk of urinary tract cancers, different cutoff values are used for prompting further evaluation. In nonsmoking women under age 50, a cutoff of >25 RBCs/HPF was recommended for determining the need for further evaluation. Women older than 50 and men with ≥3 RBCs/HPF should also be evaluated.

The most common causes of microscopic hematuria include infections and stones. Vigorous exercise or recent trauma can also cause transient hematuria. History can help determine if any of these are potential causes. A history of fever or dysuria should raise suspicion of infection and unilateral flank pain should raise concerns for a stone. A urine culture should be sent to test for infection and a urinalysis should be repeated approximately six weeks after completion of antibiotic therapy to confirm resolution of the hematuria [3]. Patients with possible stones should undergo imaging with non-contrast CT or ultrasound. In asymptomatic patients with recent trauma or frequent exercise, a urine dipstick can be repeated after a period of no exercise.

The first step in evaluation of microscopic hematuria is to send the urine for urinalysis and microscopy. This will help determine if the bleeding is from a glomerular or non-glomerular cause. Signs of glomerular bleeding include the presence of red cell casts and abnormal red cell morphology. The presence of proteinuria exceeding 500 mg/day also suggests a glomerular cause of hematuria. The timing of the proteinuria is important. If proteinuria was present prior to the onset of hematuria, a cause other than glomerular disease may be present and a full evaluation may be warranted. If glomerular bleeding is suspected, a referral to a nephrologist is recommended. Causes of glomerular bleeding are typically from immune-mediated injury to the glomeruli. Diseases such as IgA nephropathy, basement membrane nephropathy, post-infectious glomerulonephritis, and hereditary nephritis (Alport syndrome) are common causes of glomerular hematuria [4]. A renal biopsy can determine the cause, but may not be necessary in patients without evidence of progressive disease. Proteinuria, increased serum creatinine, or a rise in blood pressure would be concerning for a progressive disease. A renal biopsy is also not indicated in patients without evidence of glomerular disease.

Patients with non-glomerular hematuria should undergo evaluation for potential malignancy. Prior to this evaluation, a urine culture should be performed to rule out infection. Patients with transient or persistent hematuria and an elevated risk of malignancy should be referred for urologic evaluation. Risk factors for malignancy, as determined by the American Urological Association (AUA), are listed in Box 82.1[5]. In one study, 1.9 percent of women with microscopic hematuria between the ages of 50 and 59 had malignancy identified, and this increased to 4.5 percent in women aged 60–69 [6].

Box 82.1 Risk factors for malignancy in patients with asymptomatic hematuria

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1. Section I – Pelvic Pain
2. Section VI – Cancer Screening and Prevention
3. Section XIV – Managing and Aging
4. Section XI – Pelvic Masses and Cysts

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