Haematuria

Question 1

List differentials for haematuria

Answer 1

• Bladder cancer – painless frank haematuria
• Renal cancer
• UTI
• Stones
• Prostate disease (benign vs malignant)
• Nephrological causes
• Idiopathic

Question 2

What are the two types of haematuria?

Answer 2

1. Macroscopic (visible/ gross / frank/clots)
2. Microscopic (>5 RBC per high power field/not visible)

Other causes of red urine: Haemoglobin, Myoglobin, Beetroot, rifampicin, porphyrins

Question 3

List the differentials for the following case.

35-year old female presenting with blood in the urine and bilateral flank pain
PMH: hypertension
FH: end stage renal failure (father)
Examination: Bilateral ballotable kidneys and liver edge
Renal stone disease (Stones, obstruction, infection)

Answer 3

Renal tumours (Benign tumour e.g. angiomyolipoma (AML) Malignant tumour e.g. Renal cell carcinoma)

Infection

Trauma (e.g. biopsy)

Enlarged kidneys (Polycystic kidney diseases (e.g. ADPKD), Obstruction (e.g. papillary necrosis, ureteric/bladder tumour) )

Glomerular haematuria (IgA nephropathy)

Question 4

How do you investigate haematuria?

Answer 4

Urine analysis
•Dipstick: Blood, protein, nitrites, leucocytes, pH
• Microscopy (phase contrast? dysmorphic RBC)
• Culture
• Cytology

Bloods

Imaging:
X-ray, IV pyelogram, USS, CR urogram, MRI urogram, angiography

Question 5

When does haematuria need to be investigated further?

Answer 5

Visible or macroscopic (or ‘frank’) haematuria that occurs in a male adult patient or in a female adult patient that does not have a current UTI always requires investigation.

Microscopic haematuria can usually be regarded as at least ‘+’ of blood on a urine dipstick test on more than one occasion. The chance of a patient over 60 with microscopic haematuria having significant pathology is 5%. The possible causes are the same as for macroscopic haematuria.

Patients aged > 45 with macroscopic haematuria in the absence of proven urinary infection should be investigated with;

• -> blood tests for U+E, FBC and PSA (if male and over 50)
• -> as well as a flexible cystoscopy
• -> either a CT urogram (with and without iv contrast) OR a renal ultrasound scan.

The blood tests should ideally be carried out by the patient’s GP and the other investigations should be carried out in a one-stop haematuria clinic.

Patients aged over 45 with microscopic haematuria should have a cystoscopy and a renal ultrasound scan.

Patients aged under 45 with macroscopic haematuria in the absence of infection also require a cystoscopy and upper tract imaging.

Patients aged under 45 with microscopic haematuria do not require urological investigation.
Exceptions:
–> increased urinary frequency and urgency? = cystoscopy
–> loin pain? = non-contrast CT of the urinary tract to rule out stones.
These patients should have their renal function, blood pressure and urine protein excretion measured and should be referred to a renal physician if any abnormalities are found in these.