Haematuria

Introduction

• Painful haematuria – Stones, UTI
• Painless haematuria – More often neoplastic, hyperplastic or vascular in origin
• Gross haematuria evident with 1mL of whole blood per litre of urine
• Gross haematuria can result in false positive proteinuria as 1mL of whole blood contains 50mg albumin
  • Important when diagnosing nephritic/nephrotic syndrome
• 1-3RBC/HPF is normal
• Asymptomatic microscopic haematuria = >= 3 RBC/HPF in 2 of 3 samples

Common causes

• Infections – Any age
• Nephrolithiasis – usually >20yo
• Neoplasms – Usually >40yo (except Wilms)
• Benign prostatic hypertrophy – Males >40yo
• Glomerulonephritis – Mostly young patients and children
• Schistosomiasis – Any age. Most common cause worldwide

Differential

• Lower tract
  • Iatrogenic/post-procedural
  • Trauma
  • Infection
  • Stones/calculi
  • Tumor
  • Benign prostatic hypertrophy
  • Endometriosis

differential

• Upper tract
  • Glomerular
    • Glomerulonephritis
    • IgA nephropathy (Berger disease)
    • Lupus nephritis
    • Hereditary nephritis (Alport syndrome)
    • Toxaemia of pregnancy
    • Serum sickness
    • Erythema multiforme

differential

• Upper tract
  • Non-glomerular
    • Interstitial nephritis
    • Pyelonephritis
    • Papillary necrosis: Sickle cell, diabetes, NSAID’s
    • Vascular: AV malformations, emboli, aortocaval fistulas
    • Malignancy
    • Polycystic kidney disease
    • Medullary sponge kidney
    • TB
    • Renal trauma

differential

• Haematological
  • Primary coagulopathy
  • Pharmacological anticoagulation
  • Sickle cell disease
• Miscellaneous
  • Eroding AAA
  • Malignant hypertension
  • Loin pain-haematuria syndrome
  • Renal vein thrombosis
  • Renal artery thrombosis
  • Exercise-induced haematuria
  • Anticoagulation from snake bite

Causes of false haematuria

• Beeturia
• Munchausen/malingering/drug-seeking
• NSAID’s
• Rifampicin
• Rhubarb
• Haemoglobinuria
• Myoglobinuria
• Porphyrins

Timing of haematuria

• Initial
  • Beginning of micturition. Urethral disease
• Between voiding noticed in underpants
  • Distal urethral/meatal 
• Total haematuria
  • Bladder and up
• Terminal haematuria
  • Bladder neck or prostatic urethra

Risk factors

• If over 40, even if stone or UTI identified, warrants follow-up to ensure resolution as cancer may co-exist
• Risk factors for urothelial cancer
  • Age >40
  • Excessive analgesia use
  • Smoking
  • Dyes, benzenes, aromatic amines
  • Pelvic irradiation
  • Cyclophosphamide use

Risk factors

• Risk factors for serious causes of microscopic haematuria
  • All of above +
  • Previous urological history
  • Known malignancy
  • Sickle cell disease
  • Renal insufficiency
  • Proteinuria
• If on oral anticoagulant, should not attribute haematuria just to this as rate of coincident disease is >80%
• Renal vein thrombosis
  • Risk factors include pregnancy, dehydration, nephrotic syndrome, lymphoma and renal cell or other carcinoma
• Consider schistosomiasis if recent travel to middle east or Africa

Examination

• Vital signs
  • HTN and oedema suggest nephritic/nephrotic syndrome
  • New heart murmur or AF increases risk of embolic disease
  • Full genitourinary examination

labs

• Clean catch MSU is adequate for most
• If vaginal discharge, menstrual or vaginal bleeding consider in/out catheter
  • Induces haematuria in 15% but rarely >3RBC/HPF
• False negatives for blood
  • If high ascorbic acid content or high specific gravity
• Microscopy
  • RBC casts, RBC morphology and proteinuria suggest glomerular source

imaging

• Non-contrast CT KUB or renal USS are first-line
  • Not urgent unless clinically unwell
  • Will delineate most renal tumors, obstructions or stones
  • If no stone identified, can add contrast to examine other organs and blood flow to kidneys

Treatment, disposition and follow-up

• If no clear cause identified and clinically well need to arrange outpatient follow-up
• If <40yo: GP for repeat urinalysis within 2 weeks
  • If persistent, need referral to urology
• If >40yo: If any risk factors for urological cancer – refer to urology for review within 2 weeks
• In general population, asymptomatic haematuria alone is not associated with increased risk of urothelial malignancy
  • Is associated with 2-fold risk of developing renal failure
• In high-risk populations (e.g. elderly men), thorough investigation often reveals transitional cell carcinoma of bladder
• Any degree of proteinuria in association with asymptomatic haematuria warrants follow-up within 2 weeks
• All pregnant patients should be discussed with Urology as may accompany pre-eclampsia, pyelo or obstructing nephrolithiasis

Bladder outlet obstruction due to clot

• Triple-lumen catheter with gravity-fed drainage using saline targeting clear to light pink drainage
• Discuss with urology

Haemorrhagic cystitis

• Seen in 30-40% of females with UTI (mostly young adults)
• Rare in males so consider more sinister cause

Last Updated on October 9, 2020 by Andrew Crofton