Haematuria
Nephrology & Urology
Introduction
Author: Sarosh Ibrahim
Haematuria is a common presentation and usually signifies a concerning illness. Therefore, it is important to take a thorough history to explore the various aspects of the patients presentation. When taking a haematuria history, begin by identifying the onset and duration, determining whether it is persistent or intermittent. Distinguish between macroscopic (visible) and microscopic (dipstick-detected) haematuria. Assess for pain, as painful haematuria often suggests infection or stones, while painless haematuria raises concerns for malignancy or glomerular disease. Inquire about associated symptoms such as dysuria, urgency, fever (suggestive of infection), flank pain (stones), or weight loss (malignancy). Evaluate risk factors, including smoking, occupational exposures, recent trauma, or anticoagulant use. Finally, explore past medical history, including kidney disease, recent infections (e.g., post-streptococcal glomerulonephritis), or bleeding disorders.
WIPER
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Presenting Complaint
1. Onset:
When did the blood in the urine first appear?
Was it sudden or gradual?
2. Nature of Haematuria:
Visible (macroscopic) or non-visible (microscopic, detected on dipstick)?
Fresh red blood, dark red, or brown (“cola-coloured” urine)?
Clots present? (Suggests lower urinary tract source)
Continuous or intermittent?
3. Triggers:
Initial (beginning of stream) → Urethral source
Throughout micturition → Bladder/kidney source
Terminal (end of stream) → Bladder neck/prostate source
4. Progression:
Has it been worsening, improving, or stable over time?
5. Associated Symptoms:
Urinary Symptoms:
Dysuria (painful urination)
Frequency or urgency
Nocturia
Poor urine stream or hesitancy
Incomplete emptying
Systemic:
Fever, malaise, weight loss
Night sweats (suggests malignancy or infection)
Flank Pain:
Unilateral or bilateral?
Colicky pain (suggests kidney stones)
Dull ache (suggests infection or malignancy)
Abdominal Pain:
Suprapubic (bladder involvement)
Gastrointestinal Symptoms:
Nausea, vomiting, constipation, diarrhoea
6. Trigger/exacerbating Factors:
Does anything make it worse? (e.g., strenuous exercise, anticoagulants, dehydration)
7. Relieving Factors:
Has anything improved the symptoms?
8. Impact:
How has it affected daily life (work, mobility, appetite, anxiety levels)?
ICE: Ideas, Concerns, Expectations
Ideas: What do they think is causing the bleeding?
Concerns: Are they worried about cancer, infection, or kidney disease?
Expectations: What are they hoping for in terms of treatment and investigations?
Past Medical History
W – Wash/sanitise hands
I – Introduce yourself (name and title)
P – Permission, take consent
E – Expose the patient (if necessary)
R – Reposition the patient (if needed)
Medications
Current medications and recent changes including over the counter drugs.
Anticoagulants (warfarin, heparin, DOACs)
Anti-platelets (aspirin, clopidogrel)
NSAIDs (increase risk of renal disease)
Chemotherapy drugs (cyclophosphamide).
Recent changes in medication or over-the-counter drugs.
Family History
Family history of kidney disease, bladder cancer, or clotting disorders.
Social History
Smoking: Major risk factor for bladder cancer.
Alcohol Use: Can contribute to liver disease and clotting abnormalities.
Occupational Exposure: Chemicals (e.g., dye industry – increased bladder cancer risk).
Hydration: Poor hydration can predispose to kidney stones.
Recreational Drug Use: Cocaine can cause renal infarction.
Sexual History: STI-related urethritis (if associated with dysuria and discharge).
Explore risk factors for haematuria including:
Age > 50 (higher risk of malignancy)
Smoking history.
Exposure to industrial chemicals.
Chronic UTIs or recurrent stones.
History of pelvic radiation.
Differential Diagnosis
Haematuria may arise from the following causes:
Renal Causes:
Glomerulonephritis, polycystic kidney disease, renal cell carcinoma, kidney stones and pyelonephritis
Lower Urinary Tract Causes:
Urinary tract infection, bladder cancer, benign prostatic hyperplasia (BPH), prostatitis, urethritis (gonorrhoea, chlamydia)
Systemic Causes:
Anticoagulation or clotting disorders (haemophilia, Von Willebrand disease), sickle cell disease, liver disease (coagulopathy)
Other causes:
Exercised-induced haematuria, trauma (e.g. catheterisation or surgery (e.g. C-section)
Management
Bedside:
Physical examination to check for
Assess for pallor, jaundice (suggesting liver disease), lymphadenopathy.
Flank tenderness (renal cause)
Suprapubic tenderness (bladder involvement)
Palpable mass (suggests malignancy or large stone)
Genital Examination (if indicated):
Prostate exam in men (assess for BPH, prostate cancer).
Look for ulcers or discharge (STI-related urethritis).
Laboratory:
Blood Tests:
Full Blood Count (FBC): Infection, anaemia.
Renal Function Tests (U&E): Assess kidney function.
Inflammatory Markers (CRP, ESR): If infection or autoimmune disease suspected.
Coagulation Profile (PT, INR, APTT): If bleeding disorder suspected.
Sickle Cell Screen: If relevant.
Urine Tests:
Urinalysis: RBCs, WBCs, protein, nitrites, glucose.
Urine Culture: Rule out infection.
Urine Microscopy: Dysmorphic RBCs (glomerular disease) vs. normal RBCs (non-glomerular)
Urine Cytology: If malignancy suspected.
Imaging and Special Tests:
Renal Ultrasound: First-line for kidney abnormalities.
CT Urogram: Gold standard for detecting tumours, stones, and vascular abnormalities.
MRI Urogram: If CT not possible (e.g., contrast allergy)
Cystoscopy: Direct visualisation of bladder for suspected malignancy.
Management Plan
1. Immediate Stabilisation (If Severe Haematuria):
Monitor vital signs (hypotension, tachycardia suggest significant blood loss)
IV fluids if haemodynamically unstable.
Blood transfusion if anaemic.
Bladder irrigation if clot retention occurs.
2. Definitive Treatment Based on Underlying Cause:
UTI: Antibiotics (e.g., nitrofurantoin, trimethoprim).
Kidney Stones: Pain relief (NSAIDs, opioids), hydration, possible urological intervention.
Bladder Cancer: Referral to urology for TURBT (transurethral resection of bladder tumour)
Glomerulonephritis: Nephrology referral for immunosuppressive therapy if needed.
Prostate-related causes: Alpha-blockers for BPH, antibiotics for prostatitis.
3. Monitoring:
Regular urine dipstick and renal function tests.
Repeat imaging if symptoms persist.
4. Referral:
Urgent urology referral for macroscopic haematuria in patients >45.
Nephrology referral for suspected glomerular disease.