Define Haematuria. Describe its causes and investigations.

The Concept

Haematuria is the presence of blood in the urine, and it is a symptom that must always be taken seriously because it can be the first sign of a urological malignancy. It is classified as visible (macroscopic) or non-visible (microscopic), and the timing during the stream can hint at the source (initial — urethral; terminal — bladder base/prostate; total — bladder or upper tract).

Causes

The causes span the whole urinary tract: malignancy (bladder, kidney/renal cell carcinoma, prostate — the crucial ones to exclude), stones, infection, and BPH, along with 'medical' (glomerular) causes such as glomerulonephritis (suggested by proteinuria, red-cell casts and dysmorphic red cells). The most important clinical rule is that painless visible haematuria is a urological malignancy until proven otherwise.

Investigation

The work-up aims chiefly to exclude cancer: urinalysis and culture (infection), cystoscopy (to inspect the bladder — the key test for visible haematuria), CT urography (to image the kidneys and upper tracts), and urine cytology. Blood tests assess renal function, and features suggesting a glomerular cause prompt a nephrological rather than urological pathway.

Timing of Haematuria & Glomerular Clues

The pattern of bleeding gives clues: initial haematuria (start of the stream) points to a urethral source, terminal haematuria (end of the stream) to the bladder neck or prostate, and total haematuria to the bladder or upper tracts. Features pointing to a glomerular (medical) cause — and hence to nephrology rather than urology — include coexisting proteinuria, red-cell casts, dysmorphic red cells and hypertension. Separating surgical from medical haematuria directs the correct pathway.

The Bottom Line

Haematuria — especially painless visible haematuria — is a urological malignancy until proven otherwise, investigated by cystoscopy, CT urogram and cytology, with glomerular features directing instead to nephrology.

A Note on Non-visible Haematuria

Non-visible (microscopic) haematuria is common and often benign but still needs a considered approach: it is confirmed on repeat testing, an infection is excluded, and the decision to investigate (with cystoscopy and imaging) depends on age and risk factors, since it too can be the first sign of a urological cancer. Persistent non-visible haematuria with proteinuria or abnormal renal function is investigated as a possible glomerular disease, whereas isolated non-visible haematuria in an older smoker is investigated urologically.

Any adult with painless haematuria needs cystoscopy.

• Haematuria = blood in urine; visible (macroscopic) or non-visible (microscopic); timing hints at the source.
• Causes: malignancy (bladder, kidney, prostate — exclude), stones, infection, BPH, and glomerular/medical causes.
• Painless visible haematuria = urological malignancy until proven otherwise.
• Investigate to exclude cancer: urinalysis/culture, cystoscopy, CT urogram, urine cytology; glomerular features → nephrology.