R e s i d e n t s S e c t i o n S t r u c t u r e d R ev i ew A r t i c l e

OConnor et al.
Hematuria

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Residents Section
Structured Review Article

Residents

inRadiology
Owen J. OConnor 1
Edward Fitzgerald2
Michael M. Maher 3
OConnor OJ, Fitzgerald E, Maher MM

Imaging of Hematuria
OBJECTIVE. In this article, we will discuss the current status of imaging in patients with
hematuria of urologic origin. Issues impacting evaluation of these patients with radiography,
excretory urography, retrograde pyelography, and sonography will be discussed.
CONCLUSION. Conventional radiography has no role in the detection of renal or
urothelial carcinoma. Low-dose CT offers much greater sensitivities for the detection of uri
nary tract calculi than radiography at doses equivalent to conventional radiography. Ultra
sound alone is insufficient for imaging of hematuria. Using ultrasound alone, it is often dif
ficult to differentiate renal transitional cell carcinoma from other causes of filling defects of
the renal collecting system such as blood clots, sloughed papillae, or fungus balls. The promi
nence of the role of excretory urography in the evaluation of patients with hematuria has di
minished, and MDCT urography is now preferred to excretory urography in most cases.

Keywords: CT urography, excretory urography,

hematuria, MR urography, renal cell carcinoma,
transitional cell carcinoma, ultrasound, urothelial
carcinoma
DOI:10.2214/AJR.09.4181
Received December 23, 2009; accepted without revision
December 31, 2009.
1
Department of Radiology, University College Cork, Cork,
Ireland.
2

Department of Radiology, Mercy University Hospital,

Cork, Ireland.
3
Departments of Radiology, Cork University Hospital,
Mercy University Hospital, and University College Cork,
Wilton, Cork, Ireland. Address correspondence to M. M.
Maher (m.maher@ucc.ie).

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AJR:195, October 2010

ematuria has many causes rang

ing from urinary tract infections
to carcinoma. Imaging plays a
pivotal role in the investigation of
hematuria frequently determining the under
lying cause and influencing management. In
this article, we will discuss the current status
of imaging in patients with hematuria of uro
logic origin. Issues impacting investigation of
these patients with radiography, excretory
urography, retrograde pyelography, and sonog
raphy will be discussed. MDCT urography
and MR urography will be discussed in sepa
rate structured review articles.
Epidemiology and Pathophysiology
Hematuria has a wide range of causes in
cluding urinary tract infections (Fig. 1), cal
culi, trauma, renal parenchymal disease,
metastatic disease, and urothelial and re
nal neoplasia [1]. The most common prima
ry malignancies associated with hematuria
are renal cell carcinoma (RCC); transition
al cell carcinoma (TCC); prostate cancer;
and, less commonly, squamous cell carci
noma [1]. RCC is the most common malig
nant neoplasm of the kidney, representing
up to 90% of renal neoplasms and up to 3%
of all neoplasms [2]. Urothelial tumors rep
resent only 10% of upper urinary tract neo
plasms; however, bladder cancer is the fourth
most common cancer in the United States

[3]. Synchronous tumors occur in 2% of re

nal TCC lesions and 9% of ureteric TCC le
sions [3]. The multifocal and bilateral nature
of TCC mandates a thorough evaluation of
the urothelium and makes urothelial imag
ing challenging for the radiologist.
The prevalence of microscopic hematu
ria in asymptomatic individuals is 2.5%, and
frequently no source or cause is detected on
imaging [4]. Therefore, urinary tract imag
ing is not required in all patients who pres
ent with hematuria; the challenge is to iden
tify patients in whom imaging is indicated.
The diagnosis of a urinary tract infection or a
glomerular cause for hematuria usually obvi
ates immediate imaging and should prompt
nephrology referral [1].
Macroscopic (gross) hematuria is of more
concern than microscopic (occult) hematuria
[1]. The prevalence of carcinoma among pa
tients with macroscopic hematuria attending
a hematuria clinic has been reported to be as
high as 19% but more typically ranges be
tween 3% and 6% [5, 6]. Therefore, patients
with macroscopic hematuria require com
plete evaluation of the upper and lower uri
nary tracts with upper urinary tract imaging
and cystoscopy to exclude neoplasia.
Risk factors for carcinoma among patients
with hematuria include smoking, age of
greater than 40 years, and occupational ex
posure [7] (Appendix 1). Once the decision

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OConnor et al.

Fig. 1Imaging findings suggestive of pyelonephritis.

A, Ultrasound image of left kidney in 34-year-old woman shows wedge-shaped focus (arrow) of increased echogenicity in upper pole with expansion of cortex and
loss of corticomedullary differentiation. Normally acute pyelonephritis appears hypoechoic on ultrasound; however, in this case, hyperechogenicity is suggestive of
hemorrhage.
B, Doppler ultrasound image of same patient shown in A shows focally decreased blood flow.
C, Nephrographic phase CT image of 42-year-old man with acute pyelonephritis shows wedge-shaped area of heterogeneous attenuation (arrowhead) in interpolar
region of left kidney that extends from papillae to cortex. Kidney is enlarged, and effacement of renal sinus, loss of corticomedullary differentiation, and thickening of
perirenal fat (arrow) are noted.

to investigate hematuria has been made, one

must then choose an imaging technique ap
propriate for detection of the disease of con
cern while at the same time limiting unnec
essary radiation dose and cost.
Imaging Strategies
The best imaging strategy for patients with
hematuria remains controversial particularly
with the recent developments in CT urography
and MR urography [1]. Conventional radiog
raphy has only a moderate (60%) sensitivity
for detecting renal and urinary tract calculi but
in most circumstances remains the first-line
imaging examination [8]. The greater radia
tion dose of CT compared with radiography is
one of the most compelling arguments in favor
of the continued use of radiography, but recent
studies with low-dose CT may eliminate this
argument. Kluner et al. [9] reported that ul
tra-low-dose CT (0.5 mSv in men and 0.7 mSv
in women)with doses equivalent to that of
radiographyhad a sensitivity and specifici
ty for the detection of urinary tract calculi of
97% and 95%, respectively.
Conventional radiography is of little value
in imaging TCC and RCC, and radiography
should be avoided in patients characterized
as high risk by the American Urologic As
sociation Best Practice criteria because up
per urinary tract imaging will be required ir
respective of radiography findings [10]. The
investigation of hematuria in high-risk pa

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tients with excretory urography alone is no

longer advocated; current opinion suggests
that for a thorough evaluation of the renal
parenchyma, excretory urography should be
supplemented by ultrasound.
Excretory urography suffers other disad
vantages when compared with more modern
techniques such as CT urography or MR urog
raphy. Unlike CT urography and MR urogra
phy, excretory urography and retrograde ure
terography show only the ureteric lumen and
cannot directly depict extrinsic abnormalities
[11]. Excretory urography does not thorough
ly image the renal parenchyma next to a pelvi
caliceal abnormality or the ureteric wall, the
periureteric tissues, and the retroperitoneum.
Therefore, additional cross-sectional imaging
is frequently required to determine the cause
of a urinary tract obstruction.
The sensitivity of excretory urography is
only 21%, 52%, and 85% for detecting mass
es confirmed and characterized by CT as
measuring less than 2 cm, 23 cm, and great
er than 3 cm, respectively [6]. For the detec
tion of TCC, CT urography also compares fa
vorably with retrograde pyelography, which
enables better urothelial opacification than
excretory urography [11]. Current evidence
casts doubt on the traditional view that excre
tory urography remains the gold standard for
urothelial imaging. Larger studies comparing
MDCT urography with excretory urography
are required to resolve this matter [11].

Developments in MDCT have precipitat

ed large reductions in the number of excre
tory urography examinations performed [1].
Concerns are being expressed that the overall
quality of excretory urography examinations
has decreased because radiographers and
technologists have lost the skills needed to
obtain good-quality images, equipment qual
ity is reduced, and radiologists have dimin
ished interpretation skills because they have
been trained in an era of excretory urography
decline. The continued use of excretory urog
raphy for evaluating urolithiasis is increas
ingly difficult to justify, although it was still
considered the gold standard according to the
European Association of Urologys guide
lines for urolithiasis published in 2008 [12].
The superior diagnostic performance of CT
versus excretory urography, increased patient
acceptance, and equivalent or even lower ra
diation exposure using low-dose techniques
prompted a recent evidence-based review to
recommend CT over excretory urography for
imaging urinary calculi [13].
Ultrasound has a limited role in the detec
tion of urolithiasis but features prominently in
the European Society of Urogenital Radiology
(ESUR) guidelines for the investigation of
painless hematuria [14]. According to the
ESUR guidelines, patients are stratified into
three categories of increasing risk [14]. The in
vestigation of low-risk patients requires ultra
sound and cystoscopy. Medium-risk patients

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Hematuria

Fig. 248-year-old woman with metastatic melanoma of ureters.

A, Excretory urography image shows multiple ureteric filling defects (arrows).
B, CT scan shows multiple enhancing mural deposits (arrowheads).

cause of fungal lesions and blood clots [7].

Renal TCC occasionally produces an ob
structed infundibulum that creates a phan
tom calyx that may fill early, late, or not at
all [7]. Long-standing pelviureteric junction
obstruction and atrophy occur in a small pro
portion of patients with TCC, which produc
es a delayed nephrogram [7]. Alternatively,
acute hydronephrosis with renal enlargement
may also occur [7].
Signs of ureteric TCC include a non
functioning kidney (46%); eccentric or cir
cumferential fixed wall thickening; filling
defects; hydronephrosis (36%), with or with
out hydroureter; and irregular ureteric nar
rowing with proximal shouldering, which is
termed the goblet sign [7]. One of the dif
ficulties interpreting excretory urography or
CT urography is that urinary filling defects
can be due to primary neoplasia, metasta
ses (Fig. 2), calculi, a blood clot, a myceto
ma or infection (Fig. 3), a vascular impres
sion [11], or a congenital abnormality such
as pyeloureteritis cystica [11]. Pyeloureteri
tis cystica is seen on excretory urography as

Fig. 350-year-old man with emphysematous pyelonephritis.

A, Ten-minute excretory urography image shows delayed nephrogram (arrow) in right kidney and locules of air
projected over right renal collecting system.
B, Coronal CT scan obtained during pyelographic phase confirms air (arrowhead) in collecting system of kidney.

require ultrasound and cystoscopy; if those

tests are negative, supplemental excretory
urography or CT urography should be per
formed. High-risk patients require CT urogra
phy and cystoscopy for thorough renal and uri
nary tract imaging. Currently, ultrasound alone
is considered inadequate for evaluating micro
scopic hematuria in high-risk patients. The
sensitivity of ultrasound for detecting renal le
sions less than 1 cm is only 26%, but ultra
sound is excellent for examining the internal
architecture of cystic renal masses and deter
mining Bosniak grades, which is fundamental
to appropriate management.
Imaging Appearances
Excretory Urography
Typically a control unenhanced image cov
ering the territories of the kidneys, ureters,
and bladder is the first image obtained as part
of excretory urography. This control image is
useful for the depiction of renal parenchymal
and collecting system calculi that may not be

AJR:195, October 2010

seen after contrast administration. Medullary

calcinosis in the form of multiple punctuate
calcifications occurs in approximately 50%
of patients with medullary sponge kidney.
Medullary sponge kidney is due to dysplas
tic dilated renal collecting tubules in the pap
illary and medullary regions of the kidneys.
After contrast administration during excre
tory urography, a bunch-of-flowers appear
ance is seen due to a striated nephrogram
with filling of the ectatic ducts, which pro
duces opaque streaks of contrast material that
radiate from the renal pyramids [15].
Early urothelial neoplasms appear as sub
tle filling defects or focal mural thickening
on excretory urography. TCC can appear as
fixed, smooth or irregular, single or multi
ple filling defects within the renal collecting
systems [7]. On excretory urography, a papil
lary lesion may absorb contrast material into
its interstitium resulting in a stipple sign
[7]. Although this sign has been described
with TCC, it is nonspecific and can occur be

Fig. 4
Retrograde
pyelogram in
77-year-old
woman with
transitional cell
carcinoma of
ureter shows
filling defect
(arrow) in
mid ureter.
This finding
is sometimes
referred to as
goblet sign.
Associated
proximal
hydronephrosis
and hydroureter
are also shown.

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OConnor et al.

Fig. 681-year-old woman who presented with

hematuria. Final diagnosis was cystic renal cell
carcinoma.
A, Ultrasound image of left kidney shows mixed
solidcystic exophytic mass (arrow) in cortex of left
kidney (Bosniak category IV).
B, Unenhanced CT scan of left kidney shows kidney
(arrowhead) has abnormal contour.
C, Arterial phase CT scan obtained after contrast
administration shows avid arterial enhancement.

Fig. 568-year-old man with horseshoe kidney.

Retrograde pyelogram shows large filling defect
and expansion of lower pole collecting system on
right side. Findings are consistent with transitional
cell carcinoma.

multiple smooth round filling defects due

to small submucosal epithelium-lined cysts.
This condition is associated with urinary
tract infections and is usually asymptomatic
but may present with hematuria. Retrograde
pyelography is useful as a problem-solving
tool when filling defects are seen in the col
lecting systems and diagnostic uncertainty
exists [11] (Figs. 4 and 5).
Ultrasound
Cystic lesions can be effectively examined
using ultrasound for determining whether
wall thickening or internal septations are
present and for grading lesions using the
Bosniak classification [15]. Bosniak catego
ry I and II lesions are considered benign, and
lesions with wall and septal thickening or
solid areas are categorized as III or IV. Ul
trasound is also useful in evaluating hyperat
tenuating renal lesions detected on MDCT to
determine whether they are hyperdense cysts
(Bosniak category II) or solid lesions. One
potential pitfall is that internal echoes can
sometimes give cystic lesions a solid appear
ance at ultrasound. In this scenario, correla
tion with CT or MRI can be helpful.
RCC can appear hypoechoic, isoechoic,
or hyperechoic on sonography but is usually
isoechoic [15] (Fig. 6). Small lesions are more

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Fig. 784-year-old woman with left renal transitional

cell carcinoma who presented with hematuria.
A, Ultrasound image of left kidney shows moderate
hydronephrosis and echogenic filling defect (arrow)
in lower pole collecting system of left kidney.
B, Unenhanced CT scan shows subtle hyperdense
soft-tissue mass (arrowhead) in collecting system of
left kidney.
C, After IV contrast administration, arterial phase
CT scan shows enhancement of soft-tissue material
(arrow) in collecting system.

C
likely to be echogenic, which presents the ra
diologist with a problem in distinguishing a
small RCC from an angiomyolipoma [15].
Surveillance imaging or correlation with CT
is prudent in such cases.
Renal pelvic TCC typically appears as a cen
tral soft-tissue mass in the echogenic renal si
nus with or without hydronephrosis [7] (Fig. 7).
Renal sinus fat frequently hampers the detec
tion and exclusion of TCC in this region [15].
The sonographic appearances of TCC vary de

pending on tumor morphology, location, and

size [7, 15]. Typically, TCC may be hyperecho
ic relative to surrounding renal parenchyma
and may cast a subtle posterior acoustic shad
ow; the posterior acoustic shadowing associ
ated with TCC is usually less impressive than
that cast by calculi [7]. Central lesions can be
impossible to differentiate from blood clots,
sloughed papillae, or fungus balls [15].
The use of CT urography can be helpful in
distinguishing TCC from the other entities,

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Hematuria
and correlating imaging findings on ultra
sound and CT urography can be very help
ful. Although lesions may extend into the
renal cortex and cause focal contour distor
tion, TCC is typically infiltrative and does
not cause renal contour distortion [7].
The sensitivity of ultrasound for the detec
tion of bladder TCC has been reported as be
ing as high as 95% [15]. Bladder TCC typi
cally appears as a nonmobile mass or focus
of urothelial thickening. These findings are
not specific and must be confirmed by cys
toscopy and biopsy to exclude mimics of
TCC including cystitis, bladder outlet ob
struction, hematoma, postoperative change,
prostate carcinoma, lymphoma, neurofibro
matosis, and endometriosis [15].
Conclusion
In imaging patients with hematuria, radi
ography has no role in the detection of re
nal or ureteric neoplasms and its choice for
the detection of urinary calculi is now ques
tionable with the advent of low-dose MDCT.
Ultrasound remains an important diagnostic
tool for the evaluation of hematuria in chil
dren and in low-risk patients and for char
acterizing bladder abnormalities and cystic
renal lesions. Retrograde pyelography re
mains useful for the evaluation of indetermi
nate ureteric and bladder filling defects. Ul
trasound and excretory urography need to be
combined for the evaluation of renal and ure
teric malignancy, but CT urography and MR
urography are emerging as one-stop diagnos

tic imaging techniques that offer a thorough

evaluation of the urinary tract for urolithia
sis, renal masses, and urothelial neoplasms
in a single examination.
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APPENDIX 1: Risk Factors for the Development of Renal and Urologic Malignancies
Age > 40 years
Gross (macroscopic) hematuria
Smoking
Obesity
Analgesic abuse (e.g., phenacetin)
Exposure to chemical carcinogens (e.g., aromatic amines)
Occupational carcinogens (e.g., metal workers, painters, rubber manufacture)
Chronic inflammation of urinary tract (e.g., calculi, diverticula, and infection)
Congenital anomalies (e.g., horseshoe kidney)
Pelvic irradiation

F O R YO U R I N F O R M AT I O N

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AJR:195, October 2010

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