QuestionSBA
QuestionChoice
This may be useful in looking for metastases, but it would not be useful in diagnosing suspected renal or bladder cancer
32225
c
CT abdomen pelvis
QuestionChoice
This is usually indicated in nephrotic syndrome, acute nephritic syndrome or unexplained acute kidney injury, which is not the case here
32227
e
Renal biopsy
QuestionChoice
Guidelines state that any adult >45 years with unexplained visible haematuria without a urinary tract infection should have a 2 week referral for suspected renal or bladder cancer. Cystoscopy with biopsy is the gold standard for diagnosing bladder cancer, as it allows direct visualisation of the bladder
32223
a
Flexible cystoscopy
QuestionChoice
This is best used for excluding urinary tract obstruction and can be used to visualise cysts, abscesses, hydronephrosis and other complications of pyelonephritis. It would not be the best in investigating suspected malignancy
32224
b
Ultrasound of the kidneys, ureters and bladder
QuestionChoice
This would be useful in looking for gastrointestinal cancer, which should be suspected in a patient with unexplained iron deficiency anaemia, change in bowel habit, melaena and other constitutional symptoms
32226
d
Colonoscopy
QuestionComment
If anyone was like me and thought bladder cancer could be excluded on a KUB, then they have a low sensitivity for small cancers so should always be excluded by cystoscopy.
26771
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subscriber
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# Summary 

Haematuria, the presence of blood in the urine, can be divided into macroscopic haematuria, visible to the naked eye, and microscopic haematuria, detectable only through urinalysis. Key causes include conditions affecting the kidney, ureters, and urethra, as well as certain medications and dietary items. Clinically significant signs and symptoms vary based on the underlying cause. Key investigations include urinalysis, urine culture, and urine microscopy, as well as blood tests and imaging of the renal tract. Management strategies depend on the identified cause.

# Definitions

- Macroscopic haematuria: Blood in the urine, visible to the naked eye.
- Microscopic haematuria: Blood in the urine, detectable only on urinalysis.


# Epidemiology

The prevalence of haematuria varies depending on population characteristics such as age and sex, and the criteria used to define haematuria. In general, haematuria is more common in older individuals and in males. In clinical settings, haematuria is a common finding on urinalysis.

# Aetiology

## Kidney-related causes

- Glomerular: IgA nephropathy, Alport's syndrome, Glomerulonephritis.
- Non-glomerular: Tumours (Renal cell carcinoma, Wilm's tumour), Nephrolithiasis, Infection, Polycystic kidneys, Trauma, Urethral stricture, Vascular conditions (infarction, renal vein thrombosis), Sickle cell disease, Certain drugs.

## Ureter or Bladder-related causes

- Stones
- Tumours, particularly **Bladder Cancer**
- Strictures
- Infection

## Urethral causes

- Benign prostatic hypertrophy
- Prostate cancer
- Prostatitis
- Trauma

## Other causes

- Menstruation
- Post-coital
- Certain medications
- Viral illness

NB: Anticoagulants doesn’t in itself cause haematuria, it makes any bleeding worse. E.g. renal cancer may present with NVH, but if the patient was taking anticoagulation, this would potentiates the bleeding leading to VH. 

# Signs and Symptoms

Signs and symptoms of haematuria are largely dependent on the underlying cause and may include flank pain, abdominal pain, dysuria, frequency, urgency, and systemic symptoms such as fever or weight loss. In cases of macroscopic haematuria, patients may report pink, red, or brown urine.

# Differential Diagnosis

The differential diagnosis of haematuria includes a broad range of conditions, and the main signs and symptoms of each can help to distinguish between them:

- Glomerular diseases (e.g. IgA nephropathy, Alport's syndrome): Proteinuria, hypertension, oedema.
- Non-glomerular kidney diseases (e.g. tumours like renal cell carcinoma, Wilm's tumour): Flank pain, mass, haematuria, weight loss.
- Ureteral stones: Flank pain, haematuria, possibly signs of infection (fever, dysuria).
- Urethral conditions (e.g. benign prostatic hypertrophy, prostate cancer): Lower urinary tract symptoms (e.g. difficulty urinating, frequency), possibly haematuria.
- Pseudohaematuria: History of specific drug use or dietary intake. If there is any doubt over the legitimacy of haematuria, a lab sample should be sought. Causes of pseudohaematuria include:
	- Medications such as Rifampicin, Chlorzoxazone, Phenazopyridine, Phenothiazine, Doxorubicin, Phensuximide, Phenytoin, Daunomycin
	- Dietary items such as berries, beets, rhubarb
	- Myoglobin
	- Menstruation
- Haemoglobinuria: Occurs due to haemolysis of red blood cells.
- Myoglobinuria: Occurs due to muscle breakdown.

# Investigations

- Bedside - urinalysis.
- Urine culture.
- Urine microscopy - the type of blood cells seen may indicate the cause; dysmorphic red blood cells suggest glomerular origin, if red cell casts visible this suggests renal origin (precipitate with protein made in renal tubules)
- Blood tests: Full Blood Count (FBC), Urea and Electrolytes (U+E), Prostate-Specific Antigen (PSA) for men, and coagulation studies.
- Imaging: Renal tract ultrasound, Computed Tomography of kidneys, ureters, bladder (CT KUB).
- Cystoscopy.
- Renal biopsy.

## 2 week wait referral criteria


| Bladder cancer        | Renal cancer           | 
| ------------- |-------------| 
| If they are aged 45 years and over and have: 1) Unexplained visible haematuria without urinary tract infection, or 2) Visible haematuria that persists or recurs after successful treatment of urinary tract infection.| If they are aged 45 years and over and have: 1) Unexplained visible haematuria without urinary tract infection, or 2) Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
If they are aged 60 years and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test. | |
Consider non-urgent referral for bladder cancer in people aged 60 years and over with recurrent or persistent unexplained urinary tract infection.|   | right-aligned |

# Management

Management strategies are tailored based on the identified cause. They may include medical management for infections, surgical intervention for stones or tumours, lifestyle modification for certain causes of pseudohaematuria, or further specialist management for complex cases.

# References

[BMJ Best Practice: Assessment of visible haematuria](https://bestpractice.bmj.com/topics/en-gb/316)

[British Association of Urological Surgeons: Haematuria](https://www.baus.org.uk/patients/conditions/2/blood_in_the_urine_haematuria)

[Oxford Medical Education: Haematuria](https://www.oxfordmedicaleducation.com/wp-content/uploads/2015/04/Haematuria.protected.pdf)
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Haematuria
Topic
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Urology
6445
In adults over 45 with unexplained visible haematuria, flexible cystoscopy is essential for diagnosing potential bladder cancer.
A 65 year old gentleman presents to Accident & Emergency with a 5 day history of persistent haematuria. He has a background of atrial fibrillation and is on warfarin.


Blood tests are as follows:

||||
|--------------|:-------:|---------------|
|Haemoglobin|115  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|9.1x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|210x10<sup>9</sup>/L|150 - 400|
|Neutrophils|5.5 x10<sup>9</sup>/L|2.0 - 7.5|
|Sodium|137 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Chloride|102 mmol/L|95 - 106|
|Urea|8 mmol/L|2.5 - 7.8|
|Creatinine|95 µmol/L|60 - 120|
|eGFR|85 mL/min/1.73m<sup>2</sup>|> 60|
|International Normalised Ratio (INR)|2.1|1.0|


Urinalysis showed red blood cells with no evidence of leucocytes or nitrites. Computed tomography (CT) of kidneys, ureters and bladder showed no stones.


Which is the next most appropriate investigation?
a