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Three Part Question

In [adults with asymptomatic haematuria on anticoagulats] is [immediate GUS investigation better than delayed investigation or no investigation at all] at [detecting significant underlying pathology]?

Clinical Scenario

A 71 year old lady on warfarin for her atrial fibrillation presents to the Emergency Department with blood in her urine. You know that warfarin increases the chance of bleeding but wonder if urological investigation might reveal a significant pathologic finding.

Search Strategy

Medline using the OVID interface - 1966 to June Week 1 2005
Embase - 1980 to 2005 Week 24
CINAHL - 1982 to June Week 1 2005
Cochrane Library - Issue 2 2005
(exp. HEMATURIA OR haematuria.mp) AND (ANTICOAGULA$.mp. OR exp. ANTICOAGULANTS)
Limit to (Humans, English Language, Adults (19 and over))

Search Outcome

Medline - 221 papers found of which 4 were relevant
Embase - no additional relevant papers
CINAHL - no additional relevant papers
Cochrane Library - no additional relevant papers
1 additional paper found by a manual search of references

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Avidor et al 2000 Israel	All patients admitted due to gross haematuria while receiving warfarin or aspirin treatment between 1990 and 1998. 76 men and 17 women. Average age 76.	Retrospective cohort study	Results of evaluations in patients presenting with gross haematuria	Significant urologic pathologic finding in 69 patients (74%) including 22 (24%) previously unknown malignant tumours of the urinary tract	Only incledes gross haematuria.
Van Savage et al 1995 USA	32 consecutive patients with new onset of gross or microscopic haematuria while on anticoagulant therapy. 30 of these patients were evaluated	Prospective cohort study	Significant urinary tract disease found	9 (30%) of which 6 were symptomatic and 3 were asymptomatic	Not all patients received identical work up. 20 patients had symptoms referrable to the GU tract.
Schuster et al 1987	29 consecutive patients in whom gross or microscopic haematuria developed while they were on heparin or warfarin anticoagulant therapy	Prospective cohort study	Significant underlying pathology causing haematuria detected	17/29 (58.6%)	Full paper not available. Abstract used.
			Insignificant lesions causing haematuria detected	6/29 (20.7%)
Culclasure et al 1994 USA	Patients receiving long-term anticoagulation and controls not receiving such therapy monitored with monthly urinalysis. Patients who developed haematuria further studied for genitourinary tract diseae	Prospective cohort study	Number of subjects where genitourinary tract disease was identified	81%	Full paper not available. Abstract used.
Barkin et al 1983 Canada	270 consecutive patients who presented with haematuria over 12-month period undergoing urography and cystoscopy	Prospective study	Important underlying pathology causing haematuria found	17%	Full paper not available. Abstract used.

Comment(s)

No evidence was found to answer the part of the question querying the timescale on which the investigations should be carried out. However, a conclusion can be drawn from the data found.

Clinical Bottom Line

Adult patients on anticoagulant therapy presenting to the Emergency Department with haematuria require complete genitourinary system investigation.

References

1. Avidor Y, Nadu A, Matzkin H Clinical significance of gross hematuria and its evaluation in patients receiving anticoagulant and aspirin treatment Urology 55(1):22-4, 2000 Jan
2. Van Savage JG, Fried FA Anticoagulant associated hematuria: a prospective study Journal of Urology 153(5):1594-6, 1995 May
3. Schuster GA, Lewis GA Clinical significance of hematuria in patients on anticoagulant therapy Journal of Urology 137(5):923-5, 1987 May
4. Culclasure TF, Bray VJ, Hasbargen JA The significance of hematuria in the anticoagulated patient Archives of Internal Medicine 154(6):649-52, 1994 Mar 28
5. Barkin M, Lopatin W, Herschorn S, Comisarow R Unexplained hematuria Canadian Journal of Surgery 26(6):501-3, 1983 Nov