Haematuria

Question 1

What is haematuria?

Answer 1

Blood in the urine.
It may arise from anywhere in the renal tract.
Transient causes should be excluded e.g. UTIs and menstruation.

Question 2

How is haematuria classified?

Answer 2

Visible (macroscopic, frank)

Non-visible (microscopic, found on dipstick)

Question 3

How is non-visible haematuria classified?

Answer 3

Non-visible haematuria is subdivided based on urinary tract symptoms as symptomatic or asymptomatic.

Question 4

What does haematuria with proteinuria indicate?

Answer 4

Nephrological disorders.

Question 5

Causes of haematuria

Answer 5

Malignancy (kidney, ureter, bladder) 
Calculi 
IgA nephropathy 
Alport syndrome 
Glomerulonephritis 
PKD 
Schistosomiasis
Prostate disease 
UTIs (dysuria as well)
Radiation cystitis 
Bladder/urethral trauma 
Stones (renal colic as well)
Beetroot ingestion

Question 6

Apart from haemoglobin, what could show blood ++ on urinalysis?

Answer 6

Myoglobin triggers same dipstick reaction- check microscopy.
Rhabdomyolysis is a cause of this.

Question 7

Management of haematuria

Answer 7

-VH, SNVH, ANVH > 45 years old should undergo urological assessment, imaging and cystoscopy (cystoscopy not required in females with simple UTIs) to exclude renal tract malignancy and calculi.
- A renal aetiology should be considered and renal referral made for NVH with:
eGFR < 60
Coexistent proteinuria (A: CR > 30 or P: CR>50)
HTN > 140/90 mmHg
FHx of renal disease
-Increasing proteinuria and deteriorating eGFR warrant repeat referral and investigation.

Question 8

Why shouldn’t you refer patients under 45 with microscopic haematuria for urological investigations?

Answer 8

There’s decreased risk of renal tract malignancy and calculi.
An exception is if they have increased urinary frequency and urgency.
Check eGFR, BP, urine protein excretion- referral to a renal physician if any abnormalities are found in these.

Question 9

How should you manage a 60-year-old with painless visible haematuria?

Answer 9

Bladder cancer classically presents with painless visible haematuria.
Management:
MSU to rule out infection.
U&Es to investigate renal disease.
A flexible cystoscopy (rule out bladder tumour)
CT urogram (exclude renal and ureteric tumours and stone disease)
Serum PSA (rule out prostate cancer)