Haematuria

microscopic haematuria:

• In Australia: >10 red blood cells in high power field (HPF)
• Variations: >3–10 cells depending on British, European, or American definitions
• Prevalence: 0.19–21.0%

Macroscopic haematuria:

• More concerning than microscopic haematuria
• Prevalence of urinary tract carcinomas among patients with macroscopic haematuria: 3–6%, up to 19%

Common urological causes of haematuria:

• Urinary tract infection
• Ureteric stones – typically present with pain and microscopic haematuria
• Renal stones

Significance of haematuria:

• Suspect concurrent pathology if haematuria is significant or persistent
• If benign conditions are excluded and haematuria continues, further investigation is advised to rule out genitourinary malignancy

Recommended investigations for haematuria:

• Computed tomography intravenous pyelogram (CT IVP)
• Urine cytology
• Urine microscopy and culture
• Blood tests: full blood examination, renal function, and prostate-specific antigen (in men)

Referral to urological service:

• Patients with risk factors for genitourinary malignancy
• Patients with macroscopic haematuria
• Patients with no identified cause of haematuria
• Further investigations: cystoscopy

Anticoagulation and haematuria:

• Prevalence of haematuria is no higher in patients within the therapeutic range of anticoagulation
• Same investigations apply for anticoagulated and non-anticoagulated patients

Prevalence of identifiable causes:

• Up to 50% of patients with macroscopic haematuria have no identifiable cause
• Up to 70% of patients with microscopic haematuria have no identifiable cause
• Possible transient benign physiological conditions: vigorous physical exercise, sexual intercourse, menstrual contamination

Common causes of haematuria

Category	Cause
Benign	Renal masses (eg. angiomyolipoma, oncocytoma) Benign prostatic hypertrophy Strictures
Stones	Staghorn calculi Calcium stones Uric acid stones
Infective	Pyelonephritis Cystitis Urethritis
Trauma	Pelvic trauma Renal injuries Foreign bodies
Renal	IgA nephropathy Thin basement membrane diseases Hereditary nephritis Medullary sponge kidney
Iatrogenic	Recent endoscopic procedure (eg. transurethral resection of prostate [TURP]) Transrectal ultrasound (TRUS) guided prostate biopsy Traumatic catheterisation Radiation Indwelling ureteric stents Renal biopsies Extracorporeal shockwave lithotripsy
Malignant	Renal cell carcinoma Transitional cell carcinoma Squamous cell carcinoma Urothelial cell carcinoma Prostate acinar adenocarcimona

Risk Factors for Haematuria

• Age >40 years
• History of smoking
• History of gross haematuria
• History of chronic cystitis or irritative lower urinary tract symptoms (e.g., frequency, urgency, dysuria, nocturia, hesitancy, sensation of incomplete emptying)
• Pelvic irradiation
• Exposure to occupational chemicals and dyes (e.g., heavy phenacetin use, high doses of cyclophosphamide, aristolochic acid)

Investigations for Haematuria

Signs and Symptoms of Medical Renal Disease

• Indicators: Microscopic hematuria with dysmorphic RBCs, cellular casts, proteinuria, elevated creatinine, or hypertension.
• Suspected Conditions: IgA nephropathy, Alport syndrome, benign familial hematuria, other nephropathies.
• Action: Concurrent nephrologic workup; do not exclude urologic evaluation.

Benign Causes of Hematuria

• Common Causes: Vigorous exercise, infections, menstruation, trauma, recent urologic procedures.

• Investigation recommendations: Extensive investigations to rule out malignancy if macroscopic haematuria or risk factors are present, or if no cause is identified
• Urine Dipstick
  • Instant results for haemoglobin
  • False-Positive Rate: Up to 35%.
    • due to
      • Hemoglobinuria
      • myoglobinuria
      • semen
      • highly alkaline urine (pH >9)
      • concentrated urine.
  • Sensitivity: 91–100%
  • specificity: 65–99%
  • Positive results should be confirmed with microscopy
• Urine Microscopy, Culture, and Sensitivity (MC&S)
  • Important for ruling out urinary tract infections
  • Red cell morphology can indicate glomerular or urinary tract source
  • Albumin:creatinine ratio assesses albumin excretion
  • Positive Dipstick and Negative Microscopic Results
    • Procedure:
      • Perform three additional microscopic tests.
      • If one test is positive, confirm microscopic hematuria.
      • If all three tests are negative, no further hematuria evaluation needed.
• Urine Cytology
  • Useful for bladder and upper tract carcinomas, particularly high grade and carcinoma in situ
  • Abnormal or atypical results should be followed up with cystoscopy
  • Bladder Cancer:
    • Sensitivity:
      • High-grade bladder carcinoma and carcinoma in situ: Approximately 70-80%
      • Low-grade bladder carcinoma: Approximately 20-50%
    • Specificity: Generally high, ranging from 90-100%
  • Renal Cancer:
    • Sensitivity: Low, typically less than 50%
    • Specificity: Generally high, typically around 90-100%
• Blood Tests
  • Full blood count: assesses infection or blood loss
  • Renal function (creatinine and eGFR): checks for renal impairment
  • Prostate-specific antigen (PSA): evaluates prostate cancer risk, also raised in infections, retention, or benign prostatic hypertrophy
• Imaging
  • X-ray Kidneys, Ureters, Bladder (XR-KUB)
    • Identifies radio-opaque stones
    • Sensitivity: ~60% for detecting renal and ureteric calculi
  • Intravenous Pyelogram (IVP)
    • Injection of contrast with multiple XR-KUBs
    • Sensitivity: 50–60.5%, specificity: 90.9%
    • Largely superseded by CT
  • Ultrasound
    • Characterizes renal tumours, cysts, and hydronephrosis
    • Operator-dependent results
    • Sensitivity: 40% for renal tumours
    • Suitable for pregnant women, children, and low-risk patients
  • CT Kidney, Ureters, Bladder (CT-KUB)
    • Non-contrast study, gold standard for stones
    • Sensitivity: 94–98% for ureteric and renal stones
  • CT Intravenous Pyelogram (CT-IVP) / CT Urogram
    • Preferred for detecting genitourinary malignancy
    • Combines CT-KUB with IVP
    • Sensitivity: 94.1–100%, specificity: 97.4%
  • Cystoscopy
    • Visualizes the bladder, effective for urethral and bladder pathology
    • Requires urologist referral
    • Can biopsy tissue for analysis
    • Recommended for patients >40 years or with risk factors

Initial Management of Haematuria

• Conservative management for most cases
• Significant haematuria may require:
  • Hospital admission
  • Continuous bladder irrigation
  • Management of symptomatic anaemia
  • Catheter insertion for clot retention
  • Blood transfusions if needed
  • Emergency cystoscopy and diathermy in severe cases

Specific Conditions and Management

• Urinary Tract Infection
  • Treat empirically and modify based on sensitivities
  • Repeat urine MC&S to ensure resolution
• Ureteric and Renal Stones
  • Conservative management for stones <5 mm
  • NSAIDs for renal colic, stronger analgesia if needed
  • Alpha-blockers (prazosin, tamsulosin) for distal ureteric stones
  • Urological referral for stones unlikely to pass, causing renal impairment or sepsis
• Renal, Ureteric, and Bladder Tumours
  • Urological referral for lesions on CT-IVP or atypical cytology
  • Renal cancer: fifth most common in Australia
  • Bladder cancer: seventh most common in Australia
  • Early stage, low-grade disease treated with cystoscopy and tumour removal
• Prostatomegaly
  • Alpha-blockers (prazosin, tamsulosin) for symptom improvement
  • 5-alpha-reductase inhibitors (finasteride, dutasteride) as second-line treatment
  • Combination therapy for reducing progression of benign prostatic hypertrophy
  • Investigate prostate cancer with PSA, digital rectal examination, and referral for TRUS-guided biopsy if abnormal

Key Points

• Microscopic examination is essential for confirming hematuria.
• Positive dipstick results should be followed by microscopic analysis.
• Rule out urinary tract infection before further investigations
• Consider other causes if haematuria does not settle or if there are risk factors for malignancy
• Initial investigations should include CT-IVP, urine cytology, full blood examination, renal function, and PSA in men
• Urological referral recommended for macroscopic haematuria, persistent microscopic haematuria, abnormal urine cytology, irritative lower urinary tract symptoms, or recurrent infections