Definitions
Haematuria is the passage of blood in the urine. Frank haematuria is the presence of blood on macroscopic examination, while microscopic haematuria indicates that RBCs are only seen on microscopy. Haemoglobinuria is defined as the presence of free Hb in the urine.
Key Points
- Haematuria always requires investigation to exclude an underlying cause.
- Initial haematuria (blood on commencing urination) suggests a urethral cause.
- Terminal haematuria (blood after passing urine) suggests a bladder base or prostatic cause.
- Ribbon clots suggest a pelvi-ureteric cause.
- Renal bleeding can mimic colic due to clots passing down the ureter.
Important Diagnostic Features
Kidney
- Trauma: mild to moderate trauma commonly causes renal bleeding, severe injuries may not bleed (avulsed kidney – complete disruption).
- Tumours: may be profuse or intermittent.
- Renal cell carcinoma: associated mass, loin pain, clot, colic or fever, occasional polycythaemia, hypercalcaemia and hypertension.
- TCC: characteristically painless, intermittent haematuria.
- Calculus: severe loin/groin pain, gross or microscopic, associated infection.
- Glomerulonephritis: usually microscopic, associated systemic disease (e.g. SLE).
- Pyelonephritis (rare).
- Renal tuberculosis (rare): sterile pyuria, weight loss, anorexia, PUO, increased frequency of micturition day and night.
- Polycystic disease (rare): palpable kidneys, hypertension, chronic renal failure.
- Renal arteriovenous malformation or simple cyst (very rare): painless, no other symptoms.
- Renal infarction (very rare): may be caused by an arterial embolus, painful tender kidney.
Ureter
- Calculus: severe loin/groin pain, gross or microscopic, associated infection.
- TCC: see below.
Bladder
- Calculus: sudden cessation of micturition, pain in perineum and tip of penis.
- TCC: characteristically painless, intermittent haematuria, history of smoking, exposure to rubber or chemical dyes.
- Acute cystitis: suprapubic pain, dysuria, frequency and bacteriuria.
- Interstitial cystitis (rare): may be autoimmune, drug or radiation induced, frequency and dysuria common.
- Schistosomiasis (very rare): history of foreign travel, especially North Africa.
Prostate
- BPH: painless haematuria, associated obstructive symptoms, recurrent UTI.
- Carcinoma (rare).
Urethra
- Trauma: blood at meatus, history of direct blow to perineum, e.g. falling astride, acute retention.
- Calculus (rare).
- Urethritis (rare).
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