Haematuria

Differentials

• Common Causes

  • Bladder calculi, renal calculi

  • Urethritis (especially in men with STI risk)

  • UTI, prostatitis

  • Bladder pathologies (~70% of haematuria causes; e.g. transitional cell carcinoma)

• Other Causes

  • Exercise-induced microtrauma to kidney/bladder

  • Menstrual contamination (in women)

  • PCKD (polycystic kidney disease)

  • Prostate cancer

  • Renal cell carcinoma

  • Glomerulonephritis (e.g. IgA nephropathy, interstitial nephritis, post-streptococcal GN)

  • Anticoagulants use

  • Trauma to the renal tract

Risk Factors

• Age (≥40–50 years)

• Gross (macroscopic) haematuria history

• Irritative LUTS (frequency, urgency)

• Smoking (current or past)

• Occupational exposure to dyes, benzenes, aromatic amines

• Cyclophosphamide exposure

• Chronic/recurrent UTIs

• Pelvic irradiation history

History

• Flank pain: Suggestive of renal pathology (stones, PCKD)

• Timing of haematuria:

  • Start of stream → Urethral source

  • Throughout → Bladder or kidney origin

  • End of stream → Prostatic or bladder neck cause

• Recent trauma (loin, pelvis, genitals)

• Associated symptoms: Dysuria, LUTS, weight loss, or abdominal/back pain (possible malignancy)

• Travel history: Schistosomiasis if relevant exposures

• Exercise: Strenuous exercise might cause exercise-induced haematuria

• Bleeding elsewhere (e.g. nose, gums) → Coagulopathy or vasculitis?

• Urethral discharge → STI cause (gonococcal or chlamydial infection)

Investigations

Microscopic Haematuria

• Urine MCS: Exclude infection

• Confirm persistence: Repeat dipstick 1 week apart (≥1+ on 2 of 3 tests, ignoring “trace” results)

• Risk Stratification:

  • High Risk (male >40, smoker, occupational exposure, previous macrohaematuria)

    • Urine cytology ×3 samples (suspected urothelial malignancy)

    • Ultrasound KUB or CT IVP

    • Refer to urology (cystoscopy)

  • Glomerular Signs: Albuminuria, RBC casts, dysmorphic RBCs, eGFR decline → Nephrology referral

  • Low Risk (no risk factors, normal renal function) → Annual monitoring: dipstick, BP, ACR, eGFR

Macroscopic Haematuria

• Requires urgent investigation

• Urine MCS first to rule out infection

• Urine cytology ×3, CT IVP (or US KUB if CT contraindicated)

• Refer urology for cystoscopy

• Consider PSA in men >50 with other risk factors

Diagnosis (Prior to Referral)

• Urine MCS to identify infection or sterile pyuria

• Urine Microscopy: RBC morphology → Dysmorphic RBCs or RBC casts indicate glomerular disease

• UEC for renal function, possible CKD

• Imaging:

  • US KUB or CT IVP (depending on micro vs macrohaematuria)

  • Identify masses, stones, hydronephrosis

• Cytology ×3 for urothelial malignancy screening if indicated

• FBC: Part of referral preparation (haemoglobin, WCC, platelets)

When to Refer

Nephrology

• Persistent microscopic haematuria with proteinuria or renal impairment (eGFR decline, albuminuria)

• Dysmorphic RBCs or red cell casts (glomerular origin)

• Suspected IgA nephropathy, vasculitis, or lupus nephritis

Urology

• Any macroscopic haematuria (painful or painless)

• Persistent microscopic haematuria with risk factors (male >40, smoker, occupational exposures, recurrent UTIs)

• Unexplained haematuria with normal renal function

• Abnormal imaging findings (renal mass, bladder lesion, obstructive uropathy)

• Recurrent haematuria with LUTS despite normal PSA

Management

Microscopic Haematuria

• Low-Risk Cases: Annual check of urine dipstick, BP, ACR, eGFR

• High-Risk Cases: Immediate full workup and urological or nephrological referral

Macroscopic Haematuria

• Requires full investigation

• If symptomatic with severe pain, clot retention, or haemodynamic instability, consider urgent ED referral

• Evaluate for possible bleeding disorder if repeated or unexplained

Notes

• Red cell casts indicate glomerulonephritis or vasculitis.

• Dysmorphic RBCs suggest a glomerular source; normal RBCs indicate non-glomerular cause.

• Bladder cancer is the most common malignancy linked to haematuria (70% of malignant haematuria).

• Exercise-induced haematuria is a diagnosis of exclusion (rule out other pathology first).