Blood in the Urine (Haematuria)
What is Blood in the Urine?
A patient has haematuria, i.e., blood in the urine, when there are abnormal erythrocytes (red blood cells) in the urine.
Haematuria can be macroscopically visible (visible to the naked eye) or only microscopically detectable (in urine tests).
The condition can be painless with no other symptoms. However, it may be associated with diseases such as urinary infections and in that case more symptoms generally exist.
Haematuria is a warning sign, as it may be one of the symptoms of a severe disease, particularly cancer of the urogenital tract. The problem may originate in any of the organs where urine forms and through which it passes before leaving the body – e.g., the kidneys, ureters, bladder, urethra and prostate (in men). It may also be caused by problems of coagulation, various types of medication or kidney diseases.
Diverse risk factors exist. For example:
- Current or recent infection of the kidneys or bladder;
- Family history;
- Certain drugs (such as anticoagulants and antiaggregants);
- Intense physical exercise (it may occur after a long run or a long-distance run).
Some factors should be considered to help the urologist with detecting urinary tract cancers:
- An age of over 40;
- Occupational exposure to chemical products;
- Prior history of urological disease;
- History of “irritable” urinary symptoms;
- Urinary infections;
- History of pelvic radiotherapy.
Causes of Haematuria
Some systemic diseases, kidney diseases, such as glomerulopathies and other chronic diseases, and urinary tract cancers can cause haematuria.
The most common causes are:
- Cystitis (inflammation or infection of the bladder);
- Urinary stones;
- Bladder cancer;
- Kidney cancer;
- Prostate diseases (both malignant and benign);
- Changes in blood coagulation;
- Drugs (anticoagulants, platelet antiaggregants and others);
- Kidney diseases.
Other situations exist when the urine appears to contain blood, but which are not actually haematuria. Although the urine appears reddish in colour, this change is not caused by the presence of blood. In these cases, the causes of the change in colour are different:
- Presence of substances like bilirubin (caused by liver problems), myoglobin (from muscle tissue) or porphyrin (which occurs in some diseases);
- Ingestion of some foods (e.g., blueberries, raspberries , beetroot);
- Certain drugs.
For an accurate diagnosis, consult a urologist.
Symptoms Associated with Haematuria
Haematuria can be painless without any other associated symptoms. However, it may also be associated with other urinary tract symptoms.
For example, it may be associated with symptoms such as burning during urination, higher frequency of urination, discomfort below the navel (hypogastric or suprapubic), urinating effort, lower back or abdominal pain, etc. Depending on the associated symptoms, the causes may be different and that will determine the diagnosis and subsequent treatment.
Types of Haematuria
Haematuria is divided into two different types: macroscopic haematuria (visible) and microscopic haematuria (only detected in urine tests).
It can also be divided according to symptoms (symptomatic or asymptomatic), association with other problems (isolated or non-isolated), duration (persistent, isolated or temporary), colour (bright or dark red), presence or absence of clotting and its probable origin (renal or extra-renal).
Each of these parameters guides a different approach to achieve a correct diagnosis and determine the most suitable treatment.
Characteristics of Macroscopic Haematuria
In macroscopic haematuria, blood is visible to the naked eye and generally occurs when there is more than 1ml of blood per litre of urine.
Characteristics of Microscopic Haematuria
The urine looks normal, and blood is only detected through a microscopic examination of the urinary sediment.
When you suspect blood in the urine, the assessment must include:
- The patient’s full clinical history;
- A physical examination;
- General analyses, microscopic urine test (Urine II) and uroculture;
- Imaging exams;
It is necessary to do a vesical and renal ultrasound scan. It is also often necessary to take a CT scan that may be accompanied by a CT urogram (CTU).
If there is the least suspicion of a severe, malignant or benign urological disease, the patient should consult a urologist quickly, as it may be necessary to take more specific tests.
A urethral and bladder endoscopy (occasionally of the ureter and kidneys too) may be the only way to clarify the cause of blood in the urine. This exam – a cystoscopy or urethrocystoscopy – is far less common than digestive endoscopies (of the aesophagus, stomach or intestine) but may be essential for saving life.
A cystoscopy is the only way to diagnose early stage and therefore curable bladder cancers. Other exams, such as ultrasound and CT scans, may not be sensitive enough to detect small tumours, as with the aforementioned digestive organs. If detected at this stage, these diseases can be treated through less aggressive procedures, such as endoscopic surgery. If these cancers go untreated, the opportunity to eliminate them may be lost.
Have you noticed blood in your urine?
Treatment for Haematuria
The cause of haematuria determines what kind of treatment to use.
The treatments most necessary in the acute stage, when the haemorrhage is visible and important, are:
- Manual bladder washouts;
- Removal of bladder clots;
- Continual bladder washouts;
- Interruption in platelet antiaggregation medication;
- Antibiotic treatment.
In more severe cases, hospitalisation is necessary. Despite this, an emergency surgical procedure is rarely necessary.
Haematuria must be studied to clarify the cause of the problem in patients accurately. Very often, even after diagnosis of a mild and non-malignant case, 6–12 months of follow-up consultations are needed to confirm whether the haemorrhage has re-occurred.
In most cases, haematuria is a temporary isolated condition that does not cause severe kidney, bladder or other diseases.
However, the prognosis is not always so positive and satisfactory. One of the serious causes of this problem must be excluded. If identified, they must be treated aggressively and effectively, as they may be severe and progressive diseases.
Dr. José Santos Dias
Clinical Director of the Instituto da Próstata
- Bacherlor's Degree from the Faculty of Medicine at the University of Lisbon
- Specialist in Urology
- Fellow of the European Board of Urology
- Autor dos livros "Tudo o que sempre quis saber Sobre Próstata", "Urologia fundamental na Prática Clínica", "Urologia em 10 minutos","Casos Clínicos de Urologia" e "Protocolos de Urgência em Urologia"
FAQs about Haematuria
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- DIAS, José Santos. Urologia Fundamental: na prática clínica. Lisboa: Lidel - Edições Técnicas, Lda, 2010.
- Blood in the urine (haematuria) - https://www.baus.org.uk/patients/conditions/2/blood_in_the_urine_haematuria