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Haematuria

Table of Contents

Overview #

Definitions

  • Macroscopic = visible to the naked eye 
  • Microscopic = detected on urinary microscopy (>3 red blood cells per high-power field on urinary microscopy)

Prioritisation

  • Not an emergency unless:
    • Large volume bleeding: tachycardia, hypotension, anaemia
    • Urinary Clot retention: anuria, significant pain, distension and tenderness  

Key points 

  • Differentiate between glomerular and extraglomerular bleeding to refer appropriate to urology vs nephrology (1) 
  • Assess whether the patient has urinary/clot retention and manage in the immediate instance 
  • Malignancy needs to be excluded in all patients with haematuria (unless they are very young). Anyone over 35 years old should have full investigations for any haematuria episode, and younger patients if there are concerning features (1)

Triage #

Haemodynamically unstable → emergency requiring immediate attention

Haemodynamically stable → attend within hours

Causes #

Renal– Glomerular (1)

  • Glomerular disease (e.g. IgA nephropathy, thin basement disease, hereditary nephritis)

Renal – Extra glomerular 

  • Pyelonephritis 
  • Hydronephrosis 
  • Malignancy (e.g. renal cell carcinoma) 
  • Structural disease (e.g. polycystic kidney disease)
  • Renal vein thrombus/artery embolism 
  • Other: benign mass, malignant hypertension

Ureter 

  • Malignancy (urothelial cancer) 
  • Urolithiasis (stone)
  • Stricture 

Bladder 

  • Malignancy (e.g. transitional cell carcinoma, squamous cell carcinoma) 
  • Cystitis 
  • Urolithiasis 

Prostate/Urethra 

  • BPH, prostate cancer 
  • Post prostatic procedure (e.g. biopsy, TURP) 
  • Trauma (e.g. traumatic catheterisation) 
  • Prostatitis/urethritis 

Pseudohematuria 

  • Menstruation + postpartum women
  • Sexual intercourse, vaginal atrophy 
  • Drugs (e.g. phenytoin, rifampin, nitrofurantoin, pyridium) 
  • Beetroot 
  • Pigment (e.g. myoglobinuria, exercise induced)

Clinical features #

History 

  • Characterise hematuria 
  • Associated symptoms
    • Painful or painless? (eg. colicky flank pain – stone) 
    • History of smoking
    • Any blood clots? (clots generally indicate a urological cause/non glomerular bleeding) 
    • History of chemical exposure (eg. dyes, benzenes, aromatic amines) as well as cyclophosphamide exposure or radiotherapy 
    • History of weight loss – cancer 
    • Lower urinary tract symptoms (frequency, urgency, dysuria) 
    • Obstructive symptoms (incomplete emptying, hesitancy, reduced urinary flow) 
    • Recent upper respiratory tract infection (glomerulonephritis) (2) 
  • Any anticoagulation – consideration for reversal, or coagulopathies 
  • Recent procedures/surgery or catheter insertion 
  • Family history for kidney disease 

Examination 

  • Vital signs
    • Tachycardia/hypotension in context of significant blood loss 
    • Fever in setting of infection 
    • Blood pressure (may be elevated in glomerulopathic causes) 
    • Insert table or link from topic 3 hypotension 
  • Abdomen
    • Palpable kidney mass 
    • Flank tenderness 
    • Abdominal examination: suprapubic and low abdominal tenderness and distension. (Note in obstruction/retention bladder can extend above umbilicus)
  • Skin
    • Bruising, petechiae, telangiectasia
    • Signs of anaemia (e.g. skin pallor, conjunctival pallor etc) 
    • Urethral trauma 
    • Oedema (secondary to renal disease) 
  • Speculum exam (only if gynaecological cause suspected)
    • Exclude vaginal, cervical and uterine sources of bleeding
  • Digital rectal exam
    • Consideration for suspicion of BPH/prostate cancer

Investigations #

Initial Investigations

InvestigationIndication
Urine dipstick Nitrites and/or leukocytes indicating infection Detection of red blood cells 
FBEAnaemia, raised WCCs, platelet count in the setting of coagulopathy
UECKidney function
Coagulation Panel (PT, aPTT, INR, fibrinogen, INR) Anticoagulation or coagulopathy 
Urine MCS Urinary tract infection organism and susceptibilitiesMicroscopy for red cells (eg. dysmorphic) If transient haematuria or treated UTI, repeat in 6 weeks 
Red cell casts For suspicion of glomerular disease 

Further investigations

InvestigationIndication
Blood Cultures If considering sepsis 
AXR KUBRadio-opaque calculus (largely superseded by CT KUB)
CT KUB (kidney ureter and bladder)Renal calculus and to consider other retroperitoneal pathology 
CT IVP (intravenous pyelogram)Assessment of the renal tract for malignancy 
Renal Tract UltrasoundConsider in younger patients, recurrent renal colicMales with UTI and females with recurrent pyelonephritis 
Flexible Cystoscopy Assessment of the lower urinary tract for malignancy 
Glomerulonephritis Bloods Eg. ANA – SLE, anti glomerular basement membrane antibody – goodpastures 
Renal biopsy Glomerular hematuria and presence of progressive disease such as urine albumin excretion above 30 mg/day (3)

Management – haemodynamically unstable #

In patients with significant bleeding/hypotension: 

  • Fluid resuscitation 
  • Consider packed red blood cells 
  • Withhold anticoagulants/consider reversal and specialist haematology advice
  • Urgent specialist urology review

In patients with significant bladder pain and a bladder scan demonstrating urinary retention

  • Insert a urinary catheter 
  • If the patient has a catheter in situ and you suspect clot retention, consider a bladder washout. Seek (at least phone) advice from Urology prior to performing bladder washout as this can be associated with risk of bladder rupture. If no urology service in your institution, general surgery registrar should be able to provide advice and support.
  • Bladder washout may require a change to a larger bore IDC with 3 lumens (‘3-way’ IDC: has balloon lumen, a irrigation lumen and a drainage lumen).
  • Use sterile technique with a new catheter pack to obtain a sterile field around the catheter. Use a Toomey syringe and saline to wash the clot out of the bladder or flush out with a two way catheter (e.g. pushing in 50-100mLs of saline and drawing back saline/clots). Ensure the volume exiting the bladder is equivalent to that instilled, otherwise further bladder distension can occur increasing risk of bladder rupture. 
  • Should this fail seek specialist urological review as may need cystoscopic washout in theatre. (4) 

Refer to urology if evidence of urosepsis as an infected obstructed kidney is an emergency requiring immediate drainage (e.g. percutaneous nephrostomy insertion) 

Management – haemodynamically stable #

Malignancy needs to be excluded in all patients with haematuria (unless they are very young). Anyone over 35 years old should have full investigations for any haematuria episode, and younger patients if there are concerning features. Usual investigations include CT IVP to investigate upper renal tract and flexible cystoscopy to rule out bladder causes.

First, determine if the cause is likely a urinary tract infection or nephrolithiasis and rule out pseudohematuria through history. 

Renal colic (haematuria with unilateral flank pain) 

  • Confirm diagnosis with CT KUB (or renal tract ultrasound)
  • Analgesia (NSAIDs are very effective, consider opioids if NSAIDs contraindicated) (5) 
Indomethacin 100 mg per rectal as single dose Or Ibuprofen 400 mg oral as single dose Or Ketoralac 10 mg IM as single dose 
  • Antiemetics
  • IV fluids
  • Refer to urology and consider admission for patients with renal impairment, single kidney, recurring pain, stones >6 mm in diameter, obstruction resulting in complications such as hydronephrosis. Management options include surgical removal with uretheroscopy and laser or lithotripsy +/- ureteric stenting. In cases with infected/obstructed ureters from renal calculi ureteric stenting or nephrostomy is performed with delayed definitive management of calculi.

Urinary tract infection/pyelonephritis 

  • After treating a UTI, repeat urinalysis with microscopy after 6 weeks is warranted. If the haematuria has not resolved, further workup is needed 

After the above has been treated, it is important to differentiate glomerular vs non glomerular bleeding when determining whether urological or nephrology referral is required 

Extraglomerular Glomerular 
Colour Red/pink Red, brown or coca-cola
Clots May be present Absent 
Proteinuria <500mg/dayMay be >500mg/day 
RBC morphology Normal May be dysmorphic 
RBC casts Absent May be present 
https://www.uptodate.com/contents/etiology-and-evaluation-of-hematuria-in-adults?search=haematuria&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

Gross haematuria with visible blood clots (1) 

  • Referral to urology for cystoscopy and further evaluation 

Referral to nephrology (1) 

  • Gross haematuria without visible blood clots 
  • Microscopic haematuria with acute kidney injury and findings aligning with glomerular bleeding 

References #

  1. Perazella M, O’Leary M. Etiology and evaluation of hematuria in adults. In: Glassock R, Lam A, editors. UpToDate. [Internet]. Waltham (MA): UpToDate Inc; 2021. [updated 9 July 2021; cited 5 September 2021]. Available from: https://www.uptodate.com/contents/etiology-and-evaluation-of-hematuria-in-adults?source=history_widget#H175773655
  2. Clifford Kashtan, Simon J. Isolated and persistent glomerular haematuria in adults. In: Glassock R, Fervenza F, editors. UpToDate. [Internet]. Waltham (MA): UpToDate Inc; 2021. [updated 13 April 2020; cited 9 November 2021]. Available from: https://www.uptodate.com/contents/isolated-and-persistent-glomerular-hematuria-in-adults?search=hematuria%20in%20dwelling%20catheter&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=1
  3. Whittier W, Korbet S. The kidney biopsy. In: Glassock R, Rovin B, editors. UpToDate. [Internet]. Waltham (MA): UpToDate Inc; 2021. [updated 15 December 2020; cited 9 November 2021]. Available from: https://www.uptodate.com/contents/the-kidney-biopsy?search=hematuria%20adult&source=search_result&selectedTitle=10~150&usage_type=default&display_rank=9
  4. Schaeffer A. Placement and management of urinary bladder catheters in adults. In: Richie J, Chen W, editors. UpToDate. [Internet]. Waltham (MA): UpToDate Inc; 2021. [updated 24 March 2021; cited 9 November 2021]. Available from: https://www.uptodate.com/contents/the-kidney-biopsy?search=hematuria%20adult&source=search_result&selectedTitle=10~150&usage_type=default&display_rank=9
  5. eTG complete [Internet]. Melbourne (Vic): Therapeutic Guidelines Ltd; 2020. Renal colic; [updated 2020 Mar; cited 2021 Sep 5]. Available from: https://tgldcdp.tg.org.au/viewTopic?topicfile=renal-colic&guidelineName=Pain%20and%20Analgesia&topicNavigation=navigateTopic#toc_d1e90

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