Haematuria

Haematuria is the presence of blood in the urine. It is an important symptom that should never be ignored.

Haematuria can be macroscopic or microscopic. The patient will see the blood in the urine if it is macroscopic. He will not see it with microscopic blood. The causes for both types are the same.

Microscopic haematuria is thought to have a prevalence of 0.2% of the population. Over 50% will be diagnosed with a pathological condition. Up to 33% will have a condition that will require immediate treatment. 8% will have an underlying malignancy. It is for this reason that all cases of haematuria should be investigated.

Up to 30% of macroscopic haematuria may have an underlying malignancy.

Patients who take blood thinning drugs such as Warfarin or Plavix should never ignore haematuria. These drugs may provoke blood in the urine but are in themselves not the cause. Investigations should still be carried out to diagnose the cause. These patients have the same risk of serious pathology as the rest of the population.

Causes

Infections

Bacterial Cystitis	common
Interstitial cystitis	a rare inflammatory condition of the bladder
Prostatitis	inflammation of the prostate
Urethritis	inflammation of the urethra
Tuberculosis	rare
Schistosomiasis	a parasitic infection common in Egypt
Endocarditis	sub acute bacterial endocarditis is an uncommon condition affecting the heart valves which has blood in the urine

Stones

Kidney stones
Ureteric stones
Bladder stones

Tumours

Renal carcinoma
Ureteric carcinoma
Bladder carcinoma
Prostatic carcinoma

Inflammation

Glomerulonephritis	Inflammatory condition of the kidney
IgA nephropathy	Inflammatory condition of the kidney
Goodpastures syndrome	Inflammatory condition of the kidney
Radiation cystitis	Radiotherapy can cause inflammation of the bladder after treatment to the bladder or prostate

Trauma

Renal	Following blunt abdominal injuries
Bladder	Following catheterisation

Haematological

Anticoagulant therapy
Henoch-Schonlein Purpura	Inflammatory condition of the kidney associated with a skin rash
Coagulation disorders
Sickle cell disease	Congenital disorder affecting African negroes

Surgery

After bladder and prostate surgery

Exercise

Long distance runners can get haematuria after a long run

Differential Diagnosis

Conditions that can be confused with haematuria:

Haemoglobinuria	Haemoglobin and not red cells leaks into the urine
Food	Beetroot can colour the urine in some patients
Drugs	Nitrofurantoin and rifampicin
Porphyrias	Urine darkens on standing
Menstruation	Periods can contaminate the urine inadvertently

History

Blood in the urine may be:

Mixed throughout the stream (may have come from the kidney as there is more time for the blood to mix with the urine)
At the beginning of the stream (initial haematuria)
At the end of the stream (terminal haematuria)
These last 2 types may indicate the blood originated in the lower urinary tract as there was less time for the blood to mix

Pain is an important symptom. It may be present in urinary tract infections.

Painless haematuria may be associated with bladder tumours

Associated symptoms will occur. These include frequency nocturia (rising at night) urgency and dysuria (painful or burning voiding)

Examination

This will consist of a full abdominal examination and a digital rectal examination.

Investigations

The following tests are performed in the investigation of haematuria. Not all tests are done on every patient:

Blood tests

Full blood count will detect anaemia
ESR Erythrocyte sedimentation rate will be raised in inflammatory cases and malignancies
Urea and creatinine will detect renal failure

Urine tests

Dipstix test is a quick way of detecting blood
Microscopy confirms the presence of blood
Urine cytology may detect bladder tumours
Urine red cell morphology looks at the shape of red cells and may detect renal sources for the blood

Radiology

Plain films will pick up the majority of stones in the kidney ureter or bladder
IVU the IntraVenous Urogram is an xray of the urinary tract following injection of xray contrast medium
Ultrasound is being used more commonly to investigate haematuria
CT scanning is an xray study using xrays and computers to see the patient “in slices” It is useful in assessing renal and bladder cancers
MRI scanning is used to stage prostate cancers

Pathology

Biopsies can be performed to prove a carcinoma.
Renal biopsies are performed to show kidney problems once the routine investigations are done.

Surgery

Flexicystoscopy
This is an endoscopic examination of the bladder performed under local anaesthetic
Rigid cystoscopy
This is an endoscopic examination of the bladder carried out under general anaesthetic
Retrograde ureterogaphy
This is an xray procedure carried out at the time of a rigid cystoscopy. Dye is injected up the ureter from the bladder to visualise the ureter and renal pelvis.
Ureteroscopy
This is an endoscopic examination of the ureter by a long telescope passed up the ureter via the bladder.

The further management of the patient will obviously be dependent on the cause of the haematuria. Refer to the relevant article in the urology article section.