Hematuria, or blood in the urine, is commonly encountered in the application process. The underwriter has the sometimes difficult task of deciding which cases are benign and which require further evaluation to rule out serious causes. Hematuria can often be asymptomatic, even if serious disease is present.
Possible causes of hematuria:
There are many possible causes of hematuria. Some benign causes include urinary tract stones, menstruation, infections, prostatic hypertrophy, and vigorous exercise. Serious causes include malignancy, including kidney and bladder cancers, polycystic kidney disease, and glomerulonephritis, which encompasses a number of conditions that cause inflammation to the small vessels in the kidney that filter the blood to make urine. A cause of hematuria is sometimes not found, despite a thorough evaluation.
Some risk factors for malignancy include age over 40, a history of smoking, past radiation to the pelvic area, and gross hematuria. Gross hematuria means that blood in the urine can be seen with the unaided eye, while microscopic hematuria can only be seen through a microscope. However, urologic cancers can be present even in people without risk factors.
The evaluation of hematuria may entail relatively few or several tests, depending upon the doctor’s suspicion of serious disease. A thorough history, including family history of kidney disease, and physical examination is a useful starting place.
GLOMERULONEPHRITIS: INFLAMMATION OF TINY BLOOD VESSELS IN THE KIDNEYS THAT FILTER EXCESS FLUID, ELECTROLYTES AND WASTE FROM THE BLOODSTREAM AND PASS THEM INTO URINE. ALSO CALLED GLOMERULAR DISEASE, GLOMERULONEPHRITIS CAN BE ACUTE OR CHRONIC.
Some tests that may be performed include repeat urinalysis, although normal repeat samples may not necessarily rule out serious disease; urine for cytology, where the urine is looked at under a microscope to see if any cancer cells are present; urine for other markers suggestive of cancer; radiologic imaging, such as CT scan, sonogram, or other modalities to visualize the kidney and other components of the urinary tract; cystoscopy, in which a scope is inserted into the bladder for direct visualization for tumors; and biopsy of the kidney.
Certain findings, such as abnormal appearing red blood cells in the urine, a family history of kidney disease, or the presence of proteinuria in addition to blood, may suggest glomerulonephritis, which might prompt referral to a nephrologist, who is a physician with special training in diseases of the kidney.
When evaluating an applicant with hematuria, if the underwriter believes that a benign cause is likely, it might be possible to offer as is or perhaps with two repeat normal urine samples obtained on different days. If there is concern for serious disease then further evaluation may be requested.
Applicant 1 is a 30 year old healthy male who otherwise qualifies for Preferred Plus and is found to have a mild amount of hematuria (20 red blood cells) on the insurance labs. Two repeat samples are obtained on different days, both of which are normal. Since the applicant is at low risk for serious disease and repeat samples were negative, this applicant can be Preferred Plus.
Applicant 2 is a 60 year old smoker who otherwise qualifies for Preferred Tobacco with hematuria on the insurance labs who was postponed for evaluation and saw a urologist. All tests performed, including CT scan of the urinary tract and cystoscopy, were normal, and the urologist concluded that prostatitis was the cause. Although the applicant is at increased risk for a malignancy, since there was a complete urologic evaluation and the cause of the hematuria was benign, the hematuria history can be disregarded and this applicant can be Preferred Tobacco.
Applicant 3 is a 40 year old applicant who has hematuria and proteinuria on insurance lab testing and whom has not seen a doctor in fifteen years. The applicant’s father died at age 50 from kidney disease. The urine findings and family history suggest the presence of kidney disease, and this case needs to be postponed for evaluation by a nephrologist.