Haematuria

What are the types of haematuria?

  • Haematuria is simply blood in the urine
  • It is broadly classified as:
    • Microscopic – not visible to the naked eye. Detected either on urine dipstick or urine microscopy
    • Macroscopic – visible to the naked eye, i.e. red urine
  • It can occur due to bleeding/blood loss from any part of the urinary tract

What are the causes of haematuria?

  • The blood may arise from any part of the urinary tract.
  • It is often classified into medical causes and surgical causes
  • The most common cause of haematuria in females is urinary tract infections
  • The most common cause of haematuria in males is from Benign Prostatic Hypertrophy
  • The most concerning cause of haematuria in all patients is a urological malignancy/cancer – particularly bladder and kidney cancer
  • Urological causes of haematuria are surgical causes and include:
    • Malignancies (cancer) of the urinary tract including: kidney, ureter, bladder, prostate and urethral/penile cancers
    • Urinary tract infections
    • Benign Prostatic Hypertrophy
    • Trauma to urinary tract
    • Kidney, ureteric and bladder stones
    • Radiation change to urinary tract from previous radiotherapy
  • Medical causes include: glomerulonephritis (many subtypes), IgA nephropathy, Alport’s syndrome etc.
  • Certain blood thinning medication increase the risk of haematuria, but there still must be a source of bleeding

What investigations are required if I have haematuria?

  • All patients with blood in the urine on repeated specimens should have an evaluation
  • Investigations required include:
    • Urine microscopy and culture – will exclude infection and quantify the amount of blood in the urine. Some special forms of microscopy can help determine if the bleeding is from a medical or urological cause
    • Blood tests – Haemoglobin to ensure no anaemia if bleeding has been heavy, kidney function baseline, clotting profile
    • Urine cytology – 3 sets of urine will be collected over 3 days to check for cancerous appearing cells in the urine
    • Kidney & bladder ultrasound – will help exclude a urinary tract cancer or kidney stones.
    • CT Urogram/IVP – the gold standard Xray test for patients with haematuria. This CT scan with intravenous contrast looks at the kidney, ureters and bladder for causes.
    • Cystoscopy –  a telescopic inspection of the urethra and bladder is required to complete the evaluation in all patients.
    • Ureteroscopy – in some cases, if an abnormality of the ureter or kidney is suspected, a telescopic inspection is required. For details see Urological procedures explained.

What happens if my haematuria is suspected to arise from a medical source?

  • Medical causes will be suspected if:
    • Microscopy suggests the red blood cells in the urine arise from the kidney tissue (glomerular red cells/casts)
    • Kidney impairment exists
    • There is protein in the urine
    • Hypertension exists (high blood pressure)
  • In these cases, you will be referred to a Nephrologists (medical kidney specialist) for an evaluation. In some cases a kidney biopsy will be required to make a diagnosis

What follow up is required if my evaluation finds no cause?

  • This occurs in approximately 40% cases with microscopic haematuria and 10% cases with macroscopic haematuria
  • In these cases, follow up is dictated by your risk factors for developing a urological malignancy
  • Closer follow up is required in:
    • Older patients – >50 years age
    • Smokers – increased risk for many urological cancers
    • Those with macroscopic haematuria
    • Patients with lower urinary tract symptoms
  • As a minimum, follow up involves a repeat urine dipstick/microscopy test in 6 months. If haematuria persist, then repeat urine cytology and kidney function blood tests are required as a minimum.
  • If recurrent macroscopic haematuria occurs, a repeat evaluation is required