Men's health :: Female Urology :: Paediatric Urology
Infections :: Haematuria :: Erectile dysfunction :: Urinary Incontinence
Urinary Stones :: Vesicoureteral Reflux :: Benign Prostatic Hyperplasia :: Cancer
Haematuria is a common condition and one which must be taken seriously.
Haematuria simply means blood in urine. If you notice blood in the
urine it should always be investigated, although in most cases no
serious cause will be found.
Haematuria is usually divided into macroscopic (where the urine
is discoloured) and microscopic (where the blood is found only on
dipstick or microscopy examination). Further clinically relevant
distinctions can be made between painful and painless haematuria,
and haematuria of glomerular and post-glomerular origin.
Haematuria investigation has been made simple with the advent of
flexible cystoscopy, where the patients can assessed quickly with
a local anaesthetic outpatient procedure.
Investigations for Haematuria
General Physical Examination which includes
blood pressure, pulse, prostate in a male and the gynaecological
organs in a female
Urinanalysis- A mid stream specimen of
urine for microscopy of red, white blood cells and bacteria. The
presence of any crystals, ova or parasites should be noted and culture
of urine specimen. The level of protein in the urine will be assessed.
Blood tests- All patients should have
a full blood count with an erythrocyte sedimentation rate. Serum
urea, creatinine and electrolytes should be measured, along with
albumin, calcium and liver function tests if the patient is unwell
or in renal failure.
If no abnormality is found then a flexible cystoscopy under local anaesthetic may be performed, but if either the imaging
or this endoscopic examination suggest a bladder lesion the patient
will require a transurethral biopsy and examination under anaesthetic
for both treatment and diagnosis.
In any of the above scenarios it is important to remember that if
a particular investigation pathway leads to a negative result, consideration
should be given to carrying out the rest of the other pathways.
Thus flexible cystoscopy for a patient with persistent microscopic
haematuria in whom no renal cause is found, and ultrasound in a
patient with a normal bladder and intravenous urogram.
Points to consider about Haematuria (Blood in urine)
- Haematuria may not always be a bad thing,
- Haematuria can be detected in the urine during a menstrual period.
- It can occur only during a urine infection.
- Sometimes some medicines and foods can colour the urine red.
This is not the same as passing blood.
- It can occur following strenuous exercise.
Haematuria can originate from the kidney itself due to inflammation
in the kidney, eg glomerulonephritis affecting the filtering units
(glomeruli). When this is the cause of haematuria there are often
other signs of kidney disease such as Protein in urine, High blood
pressure or Abnormal renal function
Kidney cysts, tumours or kidney stones can also cause haematuria.
Blockages or stones in the tube to the bladder (ureter) may cause
haematuria. The bladder may also be the cause of haematuria, in
cystitis (bladder infection), stones, or tumours in the bladder.
Diseases of the prostate gland may also cause haematuria
Some conditions associated with haematuria
The commonest primary renal tumour is renal cell carcinoma, an
adenocarcinoma of collecting tubule origin. It commonly presents
with haematuria although most are nowadays picked up incidentally
by ultrasound scanning. Diagnosis is made by CT scanning and treatment
is by surgical excision. Small tumours may now be treated by local
excision with preservation of kidney function.
Transitional Cell carcinoma of the renal collecting system usually
gives haematuria. Diagnosis may be difficult, requiring retrograde
imaging and ureteroscopy. Treatment is by either local excision
or, for high grade or larger lesions, nephro-ureterectomy. Immunotherapy
is used for metastases with limited success; radiotherapy has little
place except for palliation of bone metastases.
Benign renal tumours may cause both bleeding and diagnostic difficulty.
They are, with the exception of the incidental and usually asymptomatic
renal cyst, rare. Angiomyolipoma is a hamartomatous lesion, which
may grow to great size and be associated with major haemorrhage;
treatment is again surgical, conserving normal renal tissue where
Stone disease is very common, with concretions forming in the renal
papillae, which then form a nidus for stone formation in the collecting
system. While most stones may cause infection, one particular type
(infection or matrix stone) is thought to be caused by bacteria
that are able to split urea to form ammonium. Renal stones tend
to be asymptomatic but may cause haematuria by either infection
or direct irritation of the mucosa. They may also cause renal pain
if large enough or obstructing. Diagnosis is by imaging, usually
intravenous urography. Renal stones can usually be treated by extracorporeal
shock wave lithotripsy on an outpatient basis, although large or
complex stones may need percutaneous or open surgical removal.
Glomerulonephritis tends to present with microscopic haematuria.
While pain may be associated, most cases will have either no symptoms
or may show signs of renal failure. Investigation is as outlined
Pyelonephritis (ascending urinary tract infection)
Acute bacterial pyelonephritis results from bacteria ascending
from the bladder either by direct spread (vesico-ureteric reflux)
or possibly by periureteric lymphatic extension. Painless haematuria
may occur but the symptom complex usually includes loin pain, fever
and possibly septicaemia.
This condition occurs in diabetics and in patients with deficiencies
of oxygenation, particularly sickle cell disease. It is characterised
by a radiolucent filling defect on IVU and may usually be treated
Stones may form in the kidney and drop into the tube to the bladder
(the ureter ). They usually present with pain but may have haematuria
as the only symptom. The presence or absence of obstruction and
the size of the stone dictates management. Most ureteric stones
will pass on their own but sometimes treatment by passing a telescope
up to the stone to remove it is required.
Typically cystitis is painful and in men is commonly associated
with bladder outflow obstruction. Schistosomiasis and drug related
cystitis are rarer causes of bladder inflammation causing bleeding.
Diagnosis is by urine microscopy and culture, assisted by cystoscopy
and biopsy if necessary.
Most of the interest in painless haematuria stems from the desire
to diagnose bladder tumours at an early stage. Nearly all are transitional
cell cancers, with smoking and aromatic hydrocarbon exposure being
risk factors. Rarer bladder tumours include adenocarcinoma (usually
arising from the urachus) and squamous cancer (associated with chronic
inflammation and schistosomiasis).
Diagnosis is as outlined above with management depending on the
stage and grade: 70% are superficial at presentation and are managed
by transurethral surgery with or without the use of intravesical
therapy. For invasive tumours the choice lies between radical cystectomy
or radiotherapy. Metastatic disease may respond to platinum based
Benign prostatic hyperplasia is ubiquitous but rarely bleeds on
its own: it may acute cystitis and in this case transurethral surgery
is indicated. Diagnosis is by urinary flow assessment and bladder
residual volume measurement. Prostate specific antigen levels should
be checked to rule out prostate cancer, which while uncommon in
the fifties does occur and may cause haematuria directly or by infection.
Diagnosis is by prostatic biopsy, usually with ultrasound control.
Treatment depends on the stage and outlook, but local disease may
be suitable for radical prostatectomy or radiotherapy while advanced
disease responds to hormonal manipulation.
Rare Causes of Haematuria
Arteriovenous malformations, tuberculosis and arteritis may all
cause haematuria. Patients on anticoagulants whose control is in
the normal therapeutic range and who have haematuria must be fully
investigated as above, since haematuria is not a normal consequence