BMJ Best Practice

肉眼血尿的评估

诊断步骤

肉眼血尿评估需要全面的病史与体格检查。[7] 尿液分析是肉眼血尿病情检查的关键部分，应当作为初始检测。收集新鲜、中段、清洁尿标本或者经尿管取尿标本非常重要。

The presence of white blood cells, leukocyte esterase, and nitrites points to an infectious process that should be confirmed by urine culture and treated with antibiotics. The urine should be re-tested by urinalysis, microscopy, and culture after the completion of antibiotic therapy to ensure resolution of haematuria.[18]只有在抗生素治疗完成后持续存在血尿，才需要进一步检查。出现明显蛋白尿、红细胞管型和变形红细胞需要肾内科会诊，查找肾脏本身的疾病。当老年患者出现无痛肉眼血尿，应高度怀疑为恶性肿瘤，进行尿细胞学检查。

Serum creatinine is used to assess baseline renal function and suitability for radiographic studies that require intravenous contrast. A full blood count is helpful for evaluating potential anaemia and for the presence of infection. Other blood tests may be ordered if a coagulopathy is suspected.

Imaging of the upper urinary tract should follow laboratory testing. Computed tomography is the imaging modality of choice. Finally, referral to a urologist for cystoscopy is necessary to rule out pathology of the lower urinary tract. Further investigations should be carried out in all patients with confirmed haematuria that is not explained by the above causes.

病史

Age: patients aged 35 years or older with visible haematuria are at increased risk for genitourinary tract cancer and require a full evaluation.[23]
Sex: women may have pseudohaematuria from recent intercourse, or from menses in premenopausal women.[24][25] Women tend to have more urinary tract infections than men. Pregnant women with prior caesarean sections are at risk for placenta percreta. Men have a higher incidence of urinary tract cancer.[26] Young women exposed to dieting agents containing aristolochic acid are a special population at risk for upper tract urothelial carcinoma.
尿流中出现血液的时机：排尿期间血尿出现的时机(初始，终末，全程)是确定出血来源重要线索。[27] 排尿开始出现血液，之后尿液变清亮称为初始血尿。终末血尿发生在排尿终了。初始和终末血尿表示尿道、前列腺、精囊或膀胱颈出血。全程血尿出现于整个排尿过程中，提示膀胱或上尿路（肾脏或输尿管）出血。
下尿路症状：有尿疼、尿频、尿急以及尿道分泌物个人病史提示存在感染或炎症。[28] 良性前列腺增生 (BPH) 可引起血尿和尿路梗阻症状，例如排尿等待、排尿费力以及尿不尽感。由严重 BPH 引起的尿潴留可导致尿路感染和膀胱结石形成。
疼痛：单纯血尿不会引起疼痛，除非合并炎症或急性尿路梗阻。[29] 肾盂肾炎和肾结石可以表现为侧腹痛。肾结石造成的疼痛常向腹股沟区放射。膀胱结石或血块造成的间歇性或完全性膀胱出口梗阻可表现为耻骨上区疼痛或不适。
近期剧烈体力活动：能引起自限性运动诱导血尿，但是必须排除其他重要病因。[24][25]
Inflammatory or cytotoxic mechanisms: any history of analgesic abuse should be elicited. The degree of therapeutic anticoagulation should be determined if appropriate.
Smoking/industrial chemical exposure (benzene, aromatic amines): linked to urothelial carcinomas.[24][28]
眶周和外周性水肿、体重增加、少尿、尿色深或高血压提示肾小球原因。
近期咽炎或皮肤感染：可提示感染后肾小球肾炎。
关节痛、皮疹和低热提示胶原血管病或系统性红斑狼疮。
家族史：应包括肾结石、癌症、前列腺肥大、镰状细胞贫血、胶原血管病以及肾脏疾病病史。
近期泌尿外科介入治疗：可引起复发性血尿，例如，膀胱置管，留置输尿管支架或近期前列腺活检。
Exposure to antibiotics in past 12 months: exposure to sulfonamides, nitrofurantoin, fluoroquinolones, cephalosporins, and broad-spectrum penicillins is associated with increased risk of renal stones.[30]

体格检查

生命体征：低血压和心动过速见于急性失血导致血流动力学不稳定的患者。在感染的情况下身体核心温度可能会升高。[28]
皮肤和结膜苍白：常见于贫血患者。
眶周，阴囊和周围水肿：可能提示肾小球和肾疾病所致低白蛋白血症。
恶病质：可能提示恶性肿瘤。
侧腹或脊肋角压痛：可能由肾盂肾炎或肿块（如肾肿瘤）增大引起。
耻骨上压痛：可见于感染、辐射或细胞毒性药物所致膀胱炎。[29]
膀胱排空时无法触及：充盈 200 mL 尿液的膀胱可被叩及。在急性尿潴留（通常见于 BPH 或血块导致梗阻的患者）时，膀胱可被触及，可感觉高达肚脐水平。[29]
直肠指检发现异常结节：可能意味着前列腺腺癌或浸润性膀胱肿瘤。[24] 前列腺肥大或前列腺正中叶增大是良性前列腺增生征象。
可触及淋巴结肿大：位于锁骨上或腹股沟区，可能提示肿瘤存在。
Presence of a urethral catheter, suprapubic catheter, ureteral stent, or nephrostomy tube: may signify an iatrogenic cause of bleeding that is generally benign.

实验室评估

Urine test strip analysis must be performed for dark or discoloured urine to differentiate true haematuria from pseudohaematuria caused by medications or foods.[24] 在肌红蛋白尿或血红蛋白尿的情况下可能会出现假阳性结果，通过显微镜检查未见红细胞可证实为假阳性结果。[24] 低比重尿见于肾源性疾病所致浓缩功能障碍。重度蛋白尿(>3克/天)提示肾小球肾炎。亚硝酸盐或白细胞酯酶的存在可能提示感染。
尿液显微镜检查将确认红细胞或管型的存在。每高倍视野下有 3 个或更多个红细胞（3 份独立尿液标本中有 2 份存在该情况）即为镜下血尿。[31] 明显血尿即满视野红细胞使镜检模糊，通常报告为 150 个以上红细胞/高倍视野。红细胞管型或异形红细胞提示出血来源为肾小管/肾小球。细菌、白细胞和白细胞管型提示尿路感染。尿液中存在结晶提示尿石症。
Urine cultures should be performed in patients with clinical evaluation suggestive of urinary tract infection to identify the cause, and the sensitivity data used to direct appropriate antimicrobial therapy.[28] 尿培养应使用导尿管或清洁、中段尿标本避免因污染影响结果。治疗6周后应复查尿检。[18]
对有任何尿路上皮癌风险因素的患者应行尿细胞学检查。[24][25] 这些危险因素包括：35 岁以上，吸烟史，化学品或染料职业暴露，既往有肉眼血尿，有以排尿刺激症状为主的病史，复发性尿路感染病史、滥用镇痛药，或者既往曾行盆腔放射治疗。[31] 该检测查不出肾细胞癌和前列腺癌。
全血细胞计数可用于评估严重出血病例的贫血情况。白细胞增多支持感染诊断。
Serum creatinine and estimated glomerular filtration rate (eGFR) are helpful to evaluate renal function.
In general, coagulation studies do not add to the evaluation of haematuria, and further investigations must be performed to determine the cause of bleeding. Visible haematuria in anticoagulated patients likely signifies underlying pathology.
其他特异性检查可能包括血红蛋白电泳（用于诊断镰状细胞病）或者血清补体水平检测（用于评估肾小球病变）。血清补体水平低见于感染后肾小球肾炎、系统性红斑狼疮肾炎、细菌性心内膜炎以及膜增生性肾小球肾炎。抗链球菌溶血素 O 滴度升高提示近期有链球菌感染。
Prostate-specific antigen may play a role in assessing the lower urinary tract (e.g., prostate cancer) as a source of visible haematuria.[28][29]

影像学检查

影像学检查是血尿评估的关键部分，可提供有关肾实质和上尿路的结构及功能信息。有几种检查方法可用于上尿路显像，包括超声检查 (US)、CT 尿路造影 (CTU)、磁共振尿路造影 (MRU) 和静脉尿路造影 (IVU)。
CTU 是影像学检查的首选方法，因为它可为一系列病因（从肾占位到结石乃至尿路上皮肿瘤）提供最重要的解剖细节，同时具有最高的灵敏度及特异性。[23][32]
与 IVU 相比，CTU 对于肾肿块的特点具有更强的表现力，同时，在检测上尿路上皮肿瘤方面具有更高的灵敏度。[33][34] CT 平扫也可检测肾结石，其敏感性为 94%~98%，而 IVU 的敏感性仅为 52%~59%。[35]
An ideal CTU consists of 4 distinct phases: a non-contrast phase establishes baseline tissue density and reveals urinary stones, fat, and haematoma; an arterial enhancement phase reveals inflammatory or neoplastic structures; a corticomedullary phase can show sustained renal tissue changes and damage; and a delayed excretory phase allows for evaluation of the urothelium of the ureters and bladder.[36] 用于创伤评估时，需要使用足够的造影剂以有效地评估损伤。
Prior to CTU, patient renal function should be assessed by the evaluating clinician, and a serum creatinine may be ordered to rule out impaired kidney function. The use of iodinated contrast is a well-known cause of acute renal failure in selected patients, especially those with renal insufficiency.[37] 临床医生还应该意识到造影剂严重不良反应的风险，虽然罕见，但确实有据可查。最后，临床医生应知晓每种影像学检查的电离辐射剂量，特别是诊治儿童和孕妇时。[38][39]
有 CTU 相对或绝对禁忌证的患者，可选 MRU 作为另一种影像检查方法。[40] MRU 所提供的解剖细节显像不如 CTU，但具有免于电离辐射的优势。
如果情况不允许使用 CTU 和 MRU，可将 CT 平扫或肾脏超声检查与逆行肾盂造影 (RGP) 结合，为上尿路系统提供另外一种评价方法。[23]
如果非增强 CT 扫描发现尿路结石，则应进行腹部 X 线平片检查（肾、输尿管、膀胱），以确定结石位置和放射密度，为将来的随访提供参考。经常在做 CT 尿路成像 (CTU) 时进行 CT 扫描（定位片），可以达到该目的。
For patients with suspected prostate cancer, multiparametric magnetic resonance imaging (MRI) is a useful tool to help select men for biopsy and to identify target areas for biopsy sampling.[41]
其它影像检查包括肾脏核素扫描、动脉造影和排尿期膀胱尿路造影可根据临床需要进行，但不属于初始评估。

特殊检查

Cystoscopy: during a cystoscopic examination, a rigid or flexible cystoscope is used to evaluate the urothelium of the bladder, prostate, and urethra. The ureteral orifices can be visualised, and upper tract bleeding can be seen as a jet of blood-tinged urine or clot emanating from these structures. Because urothelial carcinoma can arise from any portion of the urinary tract mucosa, complete visualisation of the bladder, bladder diverticula, and anterior and posterior urethra is necessary.[42] Prostatic hypertrophy can be seen, and associated varices that may cause bleeding can be visualised. Flexible cystoscopy has only limited usefulness in the presence of active urinary bleeding.
逆行肾盂造影 (RGP)：将对比剂注入每侧输尿管口，使输尿管和肾脏腔隙变得不透明。对不能承受 CTU 或磁共振尿路造影 (MRU) 的患者，可用逆行肾盂造影 (RGP) 代替。[25][43]
Renal biopsy: may be necessary to determine a medical renal cause of visible haematuria. Certain types of medical renal disease, such as crescentic glomerulonephritis, can quickly progress to renal failure. An urgent consultation and kidney biopsy may be necessary.

静脉穿刺和抽血的动画演示

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