Haematuria

Question 1

What is haematuria?

Answer 1

The presence of blood in the urine

Can be visible (i.e., frank) or invisible (i.e., microscopic)

Question 2

What % of patients presenting with visible haematuria have an underlying malignancy?

Answer 2

14%

Question 3

What % of patients presenting with non-visible haematuria have an underlying malignancy?

Answer 3

3%

Question 4

What are the classifications of haematuria?

Answer 4

Visible haematuria - formerly “macroscopic” or “gross” haematuria = blood is visible in the urine, colouring it pink, red, or dark brown

Non visible haematuria - formerly “microscopic” or “dipstick positive” = blood is present in the urine but not visible

Question 5

What 2 categories can non-visible haematuria (nVH) be further classified into?

Answer 5

Symptomatic NVH (s-NVH) = haematuria (confirmed on urinalysis/microscopy) presents with associated symptoms e.g., suprapubic pain or renal colic

Asymptomatic NVH (a-NVH) = haematuria (confirmed on urinalysis/microscopy) with no associated symptoms

Question 6

What are the most common causes of haematuria?

Answer 6

UTI

Renal cancer

Bladder cancer

Prostate cancer

BPH

Question 7

Name other less common causes of haematuria

Answer 7

Trauma

Radiation cystitis

Parasitic infection (most commonly schistosomiasis)

Question 8

Name medical causes of haematuria

Answer 8

Glomerulonephritis (e.g., IgA nephropathy or post-infectious glomerulonephritis)

Thin basement membrane disease

Haemolytic uraemic syndrome

Multi-system disease (e.g., HSP or Goodpasteur’s disease)

Question 9

What is pseudohaematuria?

Answer 9

Red or brown urine

Not secondary to the presence of haemoglobin

Question 10

Name causes of pseudohaematuria

Answer 10

Meds e.g., rifampicin or methyldopa

Hyperbilirubinuria

Myoglobinuria

Certain foods e.g., beetroot or rhubarb

Question 11

What are important things to remember in Hx taking for a patient presenting with haematuria?

Answer 11

Quantify degree of haematuria - pink vs dark red, clots or no clots

Timing in the stream - does the blood come all the way through the urine, at the start or at the end (total haematuria suggests bladder or upper tract source vs terminal haematuria which suggest potential severe bladder irritation)

Associated symptoms - e.g., Lower urinary tract symptoms (LUTS), fevers or rigors, suprapubic pain, flank pain, weight loss or recent trauma

DH and smoking status - strong association with smoking and urological malignancies

Any exposure to industrial carcinogens (increases risk of bladder cancer)

Recent foreign travel (increased risk of schisotomiasis from certain areas)

Question 12

What can bright pink, orange, or dark brown coloured urine suggest?

Answer 12

Non-urological causes

Question 13

Which examinations should you do in someone presenting with haematuria?

Answer 13

Abdominal exam

DRE

Examination of external genitalia

Question 14

What investigations should be done?

Answer 14

Urinalysis - primary investigation - detects nitrites and/or leukocytes

Baseline bloods
FBC
U&E
Clotting
PSA

In people with deranged renal function or suspected nephrological cause, urinary protein levels (spot albumin:creatinine ratio or protein:creatinine ratio) may be warranted

Referral to nephrology may be need in patients with a likely nephrological diagnosis, evidence of declining GFR, severe chronic kidney disease, proteinuria with haematuria, or those < 40 years old with HTN

Question 15

What are the current NICE guidelines for urgent referral to adult urology?

Answer 15

Aged ≥45yrs with either:
- unexplained visible haematuria with no UTI
- visible haematuria that persists or recurs after successful Tx of UTI

Aged 60 with:
unexplained non-visible haematuria
AND either
dysuria
OR
raised WCC on a blood test

Patients with asymptomatic non-visible haematuria on 2 out of 3 tests should also be referred for further investigation

Question 16

What is the gold standard investigation for assessing lower urinary tract?

Answer 16

Flexible cystoscopy

Should be performed in all cases of haematuria where feasible

Often performed under local anaesthetic at a one-stop haematuria clinic

Some centres will also send urine cytology in the initial assessment for haematuria as a further adjunct assessment.

Question 17

What other upper urinary tract imaging is warranted in cases of haematuria?

Answer 17

USS of the renal tract - typically done for cases of non-visible haematuria - cheap and non-invasive

CT Urogram - typically used for visible haematuria - provides more definitive imaging of the renal tract

Question 18

What is the Mx of haematuria?

Answer 18

Treat underlying pathology

Review any anticoagulation

Correct any underlying blood clotting disorders

Blood transfusions as required

Inpatient admission under Urology for patients with significant haematuria, especially those in clot retention (acute urinary retention secondary to clots obstructing the bladder outflow) - these patients will need insertion of a 3-way catheter for ongoing washout and irrigation +/- evacuation of clots

Refractory visible haematuria (esp. in patients needing multiple blood transfusions) - rigid cystoscopy +/- under general anaesthetic may be needed to control the bleeding and treat the underlying cause

Question 19

Sources

Answer 19

https://teachmesurgery.com/urology/presentations/haematuria/

https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer#urological-cancers