You will regularly see patients with blood in their urine, most often picked up incidentally on a urine drip. Your initial assessment should aim to identify whether this is due to a UTI (or other transient cause) and whether it is urological or nephrological with the help of measuring the patient’s blood pressure, bloods (FBC, U&Es, CRP) and a urine PCR. Occasionally, patients may complain of significant haematuria and an ABCDE assessment is required to assess and manage this. Here we’ve focussed on immediate investigations, management and the pathways these patients should follow.
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Definition of haematuria
- Visible haematuria (VH) is known as macroscopic or gross haematuria
- Non-visible haematuria is known as microscopic or urine dipstick positive haematuria. It may be symptomatic (sNVH) or asymptomatic (aNVH). Up to 5% of patients with aNVH are found to have a urinary malignancy.
- Significant haematuria is any episode of VH, sNVH (in the absence of a UTI or transient cause) or persistence in aNVH (across 2 of 3 urine dipstick).
- All patients with significant haematuria (with aNVH in ≥40 years) should be considered for urology referral
Common causes of haematuria
As you can imagine, blood may originate from anywhere in the urinary tract from the kidneys to the urinary meatus. The most common are:
- UTIs (by far)
- Benign prostate hypertrophy
- Renal stones
- Urethritis
- Bladder tumours
- Prostate cancer
Haematuria is a very broad topic that encompasses a wide differential diagnosis, from Urinary Tract Infection (UTI) to cancer (figure 1). Therefore, it is best to separate it into microscopic or macroscopic haematuria.
Immediate management
Visible haematuria can sometimes be a medical emergency. If there is evidence of cardiovascular collapse or acute urinary retention, the patient requires immediate management.
In patients with cardiovascular compromise:
• Resuscitate the patient with the aim of volume replacement, treatment of coagulopathy and achieving haemostasis.
• Emergency surgical intervention may be needed if there is significant bleeding of the bladder
• Blood transfusion may also be required.
In patients with acute urinary retention (usually secondary to a blood clot):
• Insert a 3-way urinary catheter (consult a senior if you have any problems catheterising)
• If a urethral injury, bladder injury or a fractured penis is suspected, obtain a urethrogram before attempting catheterisation a
• Avoid suprapubic catheterisation or bladder aspiration to prevent seeding of a potential bladder tumour
If there are no indications for admission ensure that the patient is discharged safely and that they are advised on the management of haematuria as well as when to seek medical help.
Visible haematuria
Visible haematuria, as the name suggests, is visible blood in the urine (usually pink or red)
Non-visible haematuria
According to the American Urological Association Guidelines Committee:
“The recommended definition of microscopic haematuria is 3 or more red blood cells per high-power microscopic field in urinary sediment from two of three properly collected urinalysis specimens. This definition accounts for some degree of haematuria in normal patients, as well as the intermittent nature of haematuria in patients with urologic malignancies.”
(Murphy, Crabtree, Jukkola and Soloway, 1981)” Quoted on Medscape (“What is the AUA recommended definition of microscopic haematuria?”, 2020).
A prompt referral to the Renal or Urology services in your hospital should be made once you have gathered all the information.
Summary of the common causes of haematuria
| Common causes | Features |
| UTI | LUTS +/- leucocytosis / nitrates on urine dip |
| Nephrolithiasis (Renal stones) | Flank / loin pain or sudden acute onset |
| Malignancy | Painless haematuria, check risk factors |
| Post interventional | Recent catheterisation or other procedures |
| Glomerulonephritis (or CKD) | Look for nephritic syndrome, check BP, urine PCR & discuss with renal |
| Vasculitis | Check ESR, CRP, ANA etc, look for family history and other risk factors. |
| Transient haematuria | Usually in young fit athletes |
| Mensuration | Check LMP date, or ask the patient. |
| Sexual activity / Trauma | Clinical history |
Useful links
- Oxford University Hospital – Urology referral
- Oxford University Hospital – Haematuria Pathways
- National Institute for Health and Care Excellence – Suspected cancer: recognition and referral
- Armando Hasudungan – Haematuria
References
- Medscape.com. 2020. What Is The AUA Recommended Definition Of Microscopic Hematuria?. [online] Available here. [Accessed 10 June 2020].
- Murphy, W., Crabtree, W., Jukkola, A. and Soloway, M., 1981. The Diagnostic Value of Urine Versus Bladder Washing in Patients with Bladder Cancer. Journal of Urology, 126(3), pp.320-322.
- Saikat, R., 2020. What Are Causes For Blood In The Urine, Other Than Infection?. [image] Available here. [Accessed 10 June 2020].
- Trust, C., 2020. Urology Referrals – Oxford University Hospitals. [online] Available here. [Accessed 11 June 2020].
- Dynamed – Gross Hematuria – Approach to the Adult
- Dynamed – Microhematuria – Approach to the Adult
Written by: Dr Alexander Tam (FY1)
Reviewed by Dr Sevgi Kozakli (FY4)
Edited by: Mudassar Khan (Y3 Medical Student)
