QuestionSBA
QuestionChoice
This is a less common cause of painless haematuria and there is no mention of an abdominal mass or flank pain.
10015663
c
Clear cell renal carcinoma
QuestionChoice
Urethral cancer is a much rarer cause of painless haematuria.
10015665
e
Squamous cell carcinoma of the urethra
QuestionChoice
Painless haematuria in an older male with a significant smoking history is most likely to be caused by transitional cell carcinoma of the bladder.
10015661
a
Transitional cell carcinoma of the bladder
QuestionChoice
This is more likely in a patient with chronic inflammation of the bladder (e.g. long term catheter or history of schistosomiasis). It is also less common than TCC of the bladder.
10015664
d
Squamous cell carcinoma of the bladder
QuestionChoice
This is a less common cause of painless haematuria.
10015662
b
Acinar adenocarcinoma of the prostate
QuestionComment
any tips to remember this - i keep mixing up the two *transitional and squamous
47232
QuestionComment
Squamous = things that me make me squeamish (schistosomiasis infection, long-term catheterisation)

Transitional = tobacco

Not very detailed but has helped me answer any painless haematuria Q
47283
User
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lil' aneurysm
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MadHatter09
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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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Painless visible blood in the urine in older men, particularly those who smoke, should raise concern for bladder cancer.
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Cancer
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Infection
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Surgery
A 68-year-old male comes to the GP with macroscopic haematuria. He denies any dysuria and a urine MCS does not indicate infection. He has a past medical history of GORD, IHD and COPD. He has a 20 pack-year smoking history.

Which of the following malignancies is the most likely cause of the haematuria?
a