Haematuria is the presence of red cells in urine. It is abnormal and always requires further investigation.

► It may be macroscopic (visible to the naked eye) or microscopic (when 3-5 red blood cells per high power field are seen).

► Haematuria is considered urinary tract malignancy until proven otherwise. All patients with haematuria need rapid follow up and should be referred to 2 weeks wait urology clinics. Gross haematuria more often indicates a lower tract cause, whereas microscopic haematuria tends to occur with kidney disease.

► The acute nephritic syndrome is a feature of many systemic disorders and, in addition to haematuria, there is usually proteinuria with systemic symptoms. Haematuria that varies with menstruation and is associated with severe dysmenorrhea may indicate endometriosis involving the urinary tract.

► Exercise haematuria: – can occur after non-contact strenuous exercise such as swimming and running.

► Traumatic haematuria: – is caused by blunt trauma of the posterior bladder wall against the trigone. It should settle over 48-72 h and, as long as it does, requires no further investigation.

► Post ejaculatory haematuria: – it may be associated with a urethral haemangioma or occur following prostate trauma, such as bicycling on hard saddles.

Risk factors for developing urological cancer: –

1. Age >40
2. Smoking
3. Exposure to occupational chemicals (benzenes, aniline dyes and aromatic amines)
4. Cyclophosphamide
5. Analgesic abuse
6. Prior pelvic irradiation
7. Recurrent UTI
8. Schistosomiasis infestation

Causes of Discoloured Urine: –

Colour	Cause
Dark Yellow	Drugs: chloroquine and sulphonamides Bilirubin Foods: carrots, riboflavin, vitamin A
Orange	Drugs: phenolphthalein laxatives, rifampicin, sulfasalazine
Blue Green	Pseudomonas Drugs: amitriptyline, NSAIDS, promethazine
Red Brown	Sorbitol Porphyria Foods: rhubarb, fava beans
Red	Drugs: rifampicin, phenothiazines Foods: beetroot and blackberries Haemoglobinuria Myoglobinuria

Assessing a patient with haematuria: –

Timing: –

• Initial haematuria suggests a urethral source whereas terminal haematuria indicates a bladder neck or prostatic urethra source.
• Haematuria through the stream suggests bladder or upper tract pathology.
• Haematuria occurring between voiding and noticed only as staining of underclothes with blood, while voided urine is clear, indicates lesions at the distal urethra or the meatus.
• Prostatic bleeding is usually in the setting of a strong history of prostatic symptoms.
• Gross haematuria with clots represents significant bleeding and is a worrying sign of malignancy.
• Haematuria and colicky flank pain with stringy clots may suggest upper tract bleeding.
• Constant severe lower abdominal pain and haematuria may suggest clot retention.
• Large renal cell carcinomas can invade the renal pelvis and cause frank haematuria and clot colic.

History of systemic illness: –

• A history of upper respiratory tract symptoms and possible streptococcal sore throat should be sought, to exclude post streptococcal glomerulonephritis and a consequent acute nephritic syndrome that can lead to long term renal problems.
• Gastrointestinal symptoms may be a part of haemolytic uraemic syndrome and atrial fibrillation may result in renal emboli and haematuria.

Sexual history, including recent coitus,

• It must be noted as haematuria is common post coitally.

Drug history:

• Penicillin, NSAIDS and cephalosporins can all cause interstitial nephritis.
• Cyclophosphamide can cause haemorrhagic cystitis.
• Between 4 and 24% of patients on anticoagulants can develop haematuria.

Investigations: –

► The dipstick test for blood looks at haemoglobin-like components and does not differentiate between haemoglobin from red cells and myoglobin from the breakdown of skeletal muscle.

► Routine urine culture is not needed in a young female with typical symptoms and positive nitrites and leucocytes. In all other cases – especially males, the immunocompromised, pregnant women and those with UGT obstruction and treatment failures – it is essential. 

► Careful urine microscopy is essential; red cell casts in the urine may indicate bleeding from the kidney most often due to the glomerulonephritis. White cell casts may be seen in pyelonephritis. Hyaline casts are precipitated protein; these can be seen after exercise, but granular casts are a sign of pathological proteinuria of tubular and glomerular disease.

► Imaging in haematuria investigation may involve: – Intravenous urogram (IVU), Non contrast CT, Ultrasound, rigid cystoscopy, or flexible scope

Ideally, all patients who are high risk and had a single episode of microscopic haematuria – should have an intravenous urogram and an ultrasound, as there is a risk of missing a cancer if only one is used.

Management of Gross Haematuria: –

1. The patient may require resuscitation and haematological investigations including FBC, clotting and cross match.
2. This condition requires irrigation with a three-way large haematuria catheter, until the urine is clear, and subsequent cystoscopy.
3. Failure to clear the urine through bladder washout will require a continuous infusion through one of the ports on the catheter.