What is Haematuria?
Haematuria is the presence of blood in the urine, a potentially alarming symptom that always warrants thorough investigation. It may be visible to the naked eye (frank or gross haematuria) or only detected under a microscope (microscopic haematuria). Less commonly, haemoglobinuria—presence of free hemoglobin—can mimic haematuria.
While haematuria can be painless and benign in some cases, it can also be the first warning sign of serious renal, bladder, or systemic disease.
Classifications of Haematuria
1. Gross vs. Microscopic
- Gross (Frank) Haematuria: Blood is clearly visible in the urine.
- Microscopic Haematuria: Detected only via urine microscopy.
2. Initial vs. Terminal vs. Total
- Initial Haematuria: Blood appears at the start of urination; suggests urethral origin.
- Terminal Haematuria: Blood at the end of urination; points to bladder neck or prostate.
- Total Haematuria: Blood throughout urination; suggests renal or upper tract source.
Renal Causes of Haematuria
These arise from the kidney parenchyma or collecting system.
1. Pyelonephritis
Bacterial infection of the kidney can lead to microscopic or visible haematuria, with flank pain and fever.
2. Renal Tuberculosis
Rare, but important in endemic regions. Presents with sterile pyuria, haematuria, and constitutional symptoms.
3. Renal Cell Carcinoma
Often presents with painless intermittent haematuria, flank mass, and weight loss.
4. Renal Adenoma
Benign but can still bleed.
5. Renal Cyst
May rupture or become infected, causing haematuria.
6. Renal Infarction
Ischemic damage can lead to hematuria and flank pain.
7. Arteriovenous Malformation (AVM)
Abnormal vessels may rupture and bleed into the urine.
8. Trauma
Direct blows or penetrating injury to the kidney can cause visible haematuria.
9. Glomerulonephritis
Microscopic haematuria is a hallmark. May accompany proteinuria, hypertension, or edema.
Ureteric Causes of Haematuria
The ureter connects the kidney to the bladder. Ureteric bleeding can mimic colic.
1. Ureteric Calculus (Stones)
A common cause of haematuria. Presents with loin-to-groin pain and sometimes fever or UTI.
2. Transitional Cell Carcinoma (TCC)
Can affect the renal pelvis or ureter, often painless bleeding.
3. Appendicitis
Inflammation can irritate the right ureter and occasionally lead to haematuria.
Bladder Causes of Haematuria
1. Transitional Cell Carcinoma (TCC)
The most common bladder cancer. Presents with painless intermittent haematuria, especially in smokers and those exposed to industrial chemicals or dyes.
2. Cystitis
- Acute cystitis: Suprapubic pain, urgency, frequency, burning micturition.
- Pyogenic cystitis: Bacterial origin.
- Interstitial cystitis: Chronic, possibly autoimmune.
3. Trauma
Bladder injuries from pelvic fractures or catheterization.
Urethral and Prostate Causes
1. BPH (Benign Prostatic Hyperplasia)
Common in older men. May cause painless haematuria, poor stream, and frequency.
2. Prostate Carcinoma
Advanced cases may bleed.
3. Trauma to the Urethra
Falls, catheter injuries, or external trauma can rupture blood vessels.
Key Diagnostic Clues Based on Presentation
| Type of Haematuria | Likely Origin |
|---|---|
| Blood at start of stream | Urethra |
| Blood at end of stream | Prostate or bladder neck |
| Blood throughout urine | Kidney, ureter, or bladder |
| Painless haematuria | Tumor (TCC, RCC, BPH) |
| Painful haematuria | Stones, infection, trauma |
| Ribbon-shaped clots | Pelvi-ureteric junction |
| Clots with colicky pain | Suggest renal origin |
Common Risk Factors for Haematuria
- Age > 50 years
- Smoking history
- Occupational exposure (dyes, rubber, chemicals)
- Recurrent UTIs
- Recent urinary instrumentation
- Travel to Schistosomiasis-endemic regions
Important Red Flags to Investigate
- Weight loss, night sweats, fever
- Persistent or recurrent haematuria
- Family history of renal disease
- Polycythaemia or hypertension (suggests renal tumors)
- Edema or frothy urine (suggestive of glomerular disease)
Key Investigations
To uncover the underlying cause, doctors use the following tests:
- Urinalysis & Microscopy: RBCs, WBCs, bacteria
- FBC: Anemia or signs of infection
- Ultrasound: Cysts, tumors, obstruction
- CT Urography: Detailed imaging for stones, tumors, trauma
- Cystoscopy: Direct visualization of bladder and urethra
- TRUS: Evaluate prostate disease
- Cytogram: Assesses bladder and urethral leaks or masses
Treatment of Haematuria
Treatment depends on the cause, ranging from observation to urgent intervention.
Infections
- Antibiotics for bacterial cystitis or pyelonephritis
- Antitubercular therapy for renal TB
Stones
- Hydration and analgesia for small calculi
- Lithotripsy or surgery for large or obstructive stones
Tumors
- Surgical resection (TURBT for bladder TCC)
- Nephrectomy for RCC
- Chemotherapy or immunotherapy depending on stage
BPH
- Alpha-blockers and 5-ARI (e.g., finasteride)
- TURP for severe cases
Glomerular Disease
- Immunosuppressants
- Supportive management (BP control, fluid balance)
FAQs on Haematuria
Q. Is blood in the urine always serious?
A. It should always be investigated, though not always serious. Infection and stones are common benign causes, but cancer must be ruled out.
Q. What’s the most common cause of painless haematuria?
A. Bladder cancer (TCC), especially in older adults with smoking history.
Q. Can haematuria go away on its own?
A. Some causes like minor trauma or infection may resolve, but persistent or recurrent haematuria requires workup.
Q. What foods or drugs can cause red urine?
A. Beets, rhubarb, and certain drugs (rifampin, phenazopyridine) may mimic haematuria.
Q. Is microscopic haematuria dangerous?
A. It can be benign but should still be evaluated, especially if persistent.
When to Seek Medical Help
Seek immediate attention if:
- You see visible blood in your urine
- You have fever, pain, or difficulty urinating
- Blood in urine is associated with weight loss, night sweats, or fatigue
- Clots or difficulty passing urine is present
