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
