小结
定义
肉眼不可见的血尿(non-visible haematuria, NVH)也称为镜下血尿,是指在清洁中段尿样中,每高倍视野下红细胞(red blood cell, RBC)≥3 个。[1]Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU Guideline. J Urol. 2020 Oct;204(4):778-86. https://www.auajournals.org/doi/10.1097/JU.0000000000001297 http://www.ncbi.nlm.nih.gov/pubmed/32698717?tool=bestpractice.com
尿试纸检测结果呈阳性(微量血或更多)并不能确定 NVH,而提示应该用显微镜进行进一步检查。[1]Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU Guideline. J Urol. 2020 Oct;204(4):778-86. https://www.auajournals.org/doi/10.1097/JU.0000000000001297 http://www.ncbi.nlm.nih.gov/pubmed/32698717?tool=bestpractice.com
意义
1%-3% 的 NVH 患者有尿道癌。[2]Tan WS, Feber A, Sarpong R, et al. Who should be investigated for haematuria? results of a contemporary prospective observational study of 3556 patients. Eur Urol. 2018 Jul;74(1):10-4. https://www.doi.org/10.1016/j.eururo.2018.03.008 http://www.ncbi.nlm.nih.gov/pubmed/29653885?tool=bestpractice.com [3]Samson P, Waingankar N, Shah P, et al. Predictors of genitourinary malignancy in patients with asymptomatic microscopic hematuria. Urol Oncol. 2018 Jan;36(1):10.e1-10.e6. https://www.doi.org/10.1016/j.urolonc.2017.09.011 http://www.ncbi.nlm.nih.gov/pubmed/28988782?tool=bestpractice.com
许多 NVH 病例为特发性;研究人群之间的差异可归因于年龄、性别、种族、职业和吸烟状况等因素。[4]Tomson C, Porter T. Asymptomatic microscopic or dipstick haematuria in adults: which investigations for which patients? A review of the evidence. BJU Int. 2002;90:185-198. http://www.ncbi.nlm.nih.gov/pubmed/12133052?tool=bestpractice.com [5]Wollin T, Laroche B, Psooy K. Canadian guidelines for the management of asymptomatic microscopic hematuria in adults. Can Urol Assoc J. 2009:3;77-80. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645872 http://www.ncbi.nlm.nih.gov/pubmed/19293985?tool=bestpractice.com [6]Hiatt RA, Ordonez JD. Dipstick urinalysis screening, asymptomatic microhematuria, and subsequent urological cancers in a population-based sample. Cancer Epidemiol Biomarkers Prev. 1994;3:439-443. [Published correction appears in Cancer Epidemiol Biomarkers Prev. 1994;3:523.] http://cebp.aacrjournals.org/cgi/reprint/3/5/439 http://www.ncbi.nlm.nih.gov/pubmed/7848421?tool=bestpractice.com [7]Edwards TJ, Dickinson AJ, Natale S, et al. A prospective analysis of the diagnostic yield resulting from 4020 patients at a protocol-driven haematuria clinic. BJU Int. 2006;97:301-305. http://www.ncbi.nlm.nih.gov/pubmed/16430634?tool=bestpractice.com [8]Cohen RA, Brown RS. Microscopic hematuria. N Engl J Med. 2003;348:2330-2338. http://www.ncbi.nlm.nih.gov/pubmed/12788998?tool=bestpractice.com [9]Chou R, Dana T. Screening adults for bladder cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;5:153:461-468. http://www.ncbi.nlm.nih.gov/pubmed/20921545?tool=bestpractice.com [10]Kang M, Lee S, Jeong SJ, et al. Characteristics and significant predictors of detecting underlying diseases in adults with asymptomatic microscopic hematuria: a large case series of a Korean population. Int J Urol. 2015 Apr;22(4):389-93. https://www.doi.org/10.1111/iju.12697 http://www.ncbi.nlm.nih.gov/pubmed/25581719?tool=bestpractice.com AUA: diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults Opens in new window
NVH 在人群中的患病率为 2.4%-31.1% 不等,60 岁以上的男性以及吸烟或既往吸烟男性的患病率更高。[1]Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU Guideline. J Urol. 2020 Oct;204(4):778-86. https://www.auajournals.org/doi/10.1097/JU.0000000000001297 http://www.ncbi.nlm.nih.gov/pubmed/32698717?tool=bestpractice.com [10]Kang M, Lee S, Jeong SJ, et al. Characteristics and significant predictors of detecting underlying diseases in adults with asymptomatic microscopic hematuria: a large case series of a Korean population. Int J Urol. 2015 Apr;22(4):389-93. https://www.doi.org/10.1111/iju.12697 http://www.ncbi.nlm.nih.gov/pubmed/25581719?tool=bestpractice.com
病史
最重要的一项初步诊断步骤是详细询问病史,旨在确定恶性肿瘤和肾内科疾病的危险因素。病史也可能提示不太严重的原因(例如,近期运动或性行为、泌尿道感染和月经)。
恶性肿瘤风险
泌尿道恶性肿瘤的风险随以下因素升高:年龄>40 岁、男性、血尿程度、血尿持续性、肉眼血尿史、吸烟、既往辐射暴露、尿路上皮癌(以前称为移行细胞癌)或 Lynch 综合征家族史、特定职业暴露(染料、苯系物、芳香胺类)、药物(例如环磷酰胺或异环磷酰胺化疗,以及部分草药减肥药所含马兜铃酸)。[8]Cohen RA, Brown RS. Microscopic hematuria. N Engl J Med. 2003;348:2330-2338. http://www.ncbi.nlm.nih.gov/pubmed/12788998?tool=bestpractice.com 在男性中,无症状 NVH 更可能与泌尿道恶性肿瘤有关。[11]American College of Obstetricians and Gynecologists' Committee on Gynecologic Practice, American Urogynecologic Society. Committee opinion no. 703: asymptomatic microscopic hematuria in women. Jun 2017 [Internet publication]. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/06/asymptomatic-microscopic-hematuria-in-women [3]Samson P, Waingankar N, Shah P, et al. Predictors of genitourinary malignancy in patients with asymptomatic microscopic hematuria. Urol Oncol. 2018 Jan;36(1):10.e1-10.e6. https://www.doi.org/10.1016/j.urolonc.2017.09.011 http://www.ncbi.nlm.nih.gov/pubmed/28988782?tool=bestpractice.com 肥胖和高血压是肾细胞癌的危险因素。[12]Escudier B, Porta C, Schmidinger M, et al. Renal cell carcinoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2019 May 1;30(5):706-20. https://www.esmo.org/guidelines/genitourinary-cancers/renal-cell-carcinoma http://www.ncbi.nlm.nih.gov/pubmed/30788497?tool=bestpractice.com
如果基于高风险或中等风险特征怀疑是恶性肿瘤,则需要对整个尿道进行评估,包括上泌尿道影像学检查和下泌尿道的膀胱镜检查。[1]Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU Guideline. J Urol. 2020 Oct;204(4):778-86. https://www.auajournals.org/doi/10.1097/JU.0000000000001297 http://www.ncbi.nlm.nih.gov/pubmed/32698717?tool=bestpractice.com 相比之下,低危患者的诊断检查更加关注可疑病因,而无需进行完整的泌尿道检查。英国国家卫生与临床优化研究所的推荐指出,如果≥60 岁的患者出现不明原因 NVH,并且存在尿痛或血检白细胞计数升高,则应按照疑似膀胱癌转诊路径转诊(以便在转诊 28 日内确诊或排除癌症)。[13]National Institute for Health and Care Excellence. Suspected cancer: recognition and referral. Oct 2023 [internet publication]. https://www.nice.org.uk/guidance/ng12
分类标准
考虑出血的解剖部位来源,能够提供一种系统化的分类方案。上尿路包括肾脏(肾小球或非肾小球性)和输尿管,剩余的部分为下尿路。这些分类标准在病史询问和体格检查时有很大价值,同时,这也可体现在安排诊断性检查时,因为没有单项诊断性检查能全面评估整个尿路。
诊断性检查
诊断性检查必须首先确认存在 NVH。此后,检查可能鉴别上泌尿道肾小球源性血尿与其他原因引起的血尿,从而完成更精确的诊断检查。但是,对于具有泌尿道恶性肿瘤危险因素的所有患者,仍然有必要进行上泌尿道和下泌尿道的诊断性检查(影像学检查和膀胱镜检查)。
筛查
在 NVH 患者中最常发现的癌症是尿路上皮癌。[7]Edwards TJ, Dickinson AJ, Natale S, et al. A prospective analysis of the diagnostic yield resulting from 4020 patients at a protocol-driven haematuria clinic. BJU Int. 2006;97:301-305. http://www.ncbi.nlm.nih.gov/pubmed/16430634?tool=bestpractice.com [14]Messing EM, Madeb R, Young T, et al. Long-term outcome of hematuria home screening for bladder cancer in men. Cancer. 2006;107:2173-2179. http://onlinelibrary.wiley.com/doi/10.1002/cncr.22224/full http://www.ncbi.nlm.nih.gov/pubmed/17029275?tool=bestpractice.com [15]Friedman GD, Carroll PR, Cattolica EV, et al. Can hematuria be a predictor as well as a symptom or sign of bladder cancer? Cancer Epidemiol Biomarkers Prev. 1996;5:993-996. http://cebp.aacrjournals.org/cgi/reprint/5/12/993 http://www.ncbi.nlm.nih.gov/pubmed/8959322?tool=bestpractice.com [16]Sugimura K, Ikemoto S, Kawashima H, et al. Microscopic hematuria as a screening marker for urinary tract malignancies. Int J Urol. 2001;8:1-5. http://www.ncbi.nlm.nih.gov/pubmed/11168689?tool=bestpractice.com [17]Jones R, Latinovic R, Charlton J, et al. Alarm symptoms in early diagnosis of cancer in primary care: cohort study using general practice research database. BMJ. 2007;334:1040. http://www.bmj.com/cgi/content/full/334/7602/1040 http://www.ncbi.nlm.nih.gov/pubmed/17493982?tool=bestpractice.com
美国预防服务工作组(US Preventive Services Task Force)建议不要进行常规筛查,估计提示膀胱癌的 NVH 阳性预测值为 5%-8%。[9]Chou R, Dana T. Screening adults for bladder cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;5:153:461-468. http://www.ncbi.nlm.nih.gov/pubmed/20921545?tool=bestpractice.com [18]Nielsen M, Qaseem A; High Value Care Task Force of the American College of Physicians. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016;164:488-497. http://annals.org/article.aspx?articleid=2484287 http://www.ncbi.nlm.nih.gov/pubmed/26810935?tool=bestpractice.com
鉴别诊断
常见
- 月经
- 膀胱炎(泌尿道感染)
- 肾盂肾炎
- 肾结石
- 急性前列腺炎
- 良性前列腺增生 (BPH)
- 外伤(性生活、运动、挫伤)
不常见
- 梗阻性肾病
- 肾细胞癌
- 尿路上皮癌(上尿路)
- 单纯性肾囊肿
- 多囊肾病
- 海绵肾
- 萎缩肾
- 肾盏憩室
- 肾脏梗死
- 肾静脉血栓
- 动静脉畸形
- 乳头坏死
- 镰状细胞病
- 肾(盂)积水
- 肾孟输尿管连接部梗阻
- 膀胱输尿管反流
- IgA 肾病
- 薄肾小球基底膜病
- 急性肾小球肾炎
- 狼疮肾炎
- 遗传性肾炎(Alport综合征)
- 尿路上皮癌(膀胱)
- 膀胱炎(间质性)
- 膀胱炎(放射性)
- 膀胱炎(嗜酸细胞性)
- 膀胱憩室
- 膀胱乳头状瘤
- 前列腺癌
- 前列腺结石
- 膀胱颈挛缩
- 尿道炎
- 尿道狭窄
- 包茎
- 阴茎癌
- HIV
- 淋巴瘤
- 多发性骨髓瘤
- 尿路结核
撰稿人
作者
Timothy J. Benton, MD
Regional Chairman
Professor
Department of Family and Community Medicine
Texas Tech University Health Sciences Center at the Permian Basin
Odessa
TX
利益声明
TJB declares that he has no competing interests.
Beverly Axe-Lewis, DO
Associate Professor
Regional Chief Medical Informatics Officer
Medical Director Haven Health Clinics
Department of Family Medicine
Texas Tech University Health Sciences Center
Amarillo
TX
利益声明
BAL declares that she has no competing interests.
同行评议者
Brian J. Linder, MD, MS
Associate Professor of Urology and Obstetrics/Gynecology
Mayo Clinic
Rochester
MN
利益声明
BJL declares that he has no competing interests.
Robert Tompkins, MD
Associate Professor
Department of Family Medicine
University of Texas Health Science Center
Tyler
TX
利益声明
RT declares that he has no competing interests.
Junaid Masood, MBBS, FRCS (Eng), MSc (Urol), FRCS (Urol)
Consultant Urological Surgeon
Bart's and The London NHS Trust
London
UK
利益声明
JM declares that he has no competing interests.
指南
- 镜下血尿:AUA/SUFU 指南
- 加拿大妇产科学会临床治疗指南:反复复发的泌尿系感染
更多 指南- 登录或订阅即可浏览 BMJ Best Practice 临床实践完整内容
内容使用需遵循免责声明