The basics - Visible haematuria

Careful assessment is needed when patients present with this worrying symptom, advises Dr Kamilla Porter.

Urological cancer may first present with haematuria and UTI
Urological cancer may first present with haematuria and UTI

A patient presenting with visible haematuria (VH) - also called frank or macroscopic haematuria - requires careful assessment. It is necessary to clarify that the blood is indeed coming from the urethra rather than from the rectum or vagina.

Urine discoloration may result from other causes, including the consumption of beetroot, more rarely myoglobinuria, haemoglobinuria or drugs such as rifampicin, nitrofurantoin and doxorubicin.

Initial Investigations
  • Dipstick urine to exclude transient cause including UTI.
  • MSU if clinically indicated.
  • Plasma creatinine/eGFR.

Other relevant aspects of the history include smoking status, any past urological problems, occupational history and whether the patient is on antiplatelet or anticoagulant therapy.

It is important to enquire whether there are any associated symptoms such as dysuria, frequency, urgency (lower urinary tract symptoms, LUTs), loin pain or whether the haematuria is painless (a red flag symptom).

The guidelines in the recent consensus statement from the Renal Association and British Association of Urological Surgeons stipulate that all cases of VH are significant and require further investigation, including patients taking warfarin or antiplatelet therapy.1

Diagnosis
One of the most common causes of VH in general practice is a UTI. It is reasonable to prescribe empirical antibiotic treatment with a clear history of cystitis symptoms associated with VH, particularly in young women.

However, even in these cases it is recommended that after treatment (ideally seven days after completing antibiotics) a urine dipstick is repeated to confirm that the haematuria has completely resolved.

Significant haematuria is considered to be 1+ or more on dipstick and trace haematuria should be regarded as negative.1 If haematuria is identified on dipstick, routine laboratory confirmation is not necessary.

It should be remembered that a UTI (irrespective of the presence of haematuria) can be the first presentation of a urological pathology. Furthermore, the NICE cancer guidelines recommend urgent referral of patients aged over 40 years with recurrent or persistent UTI associated with haematuria.2

Referral
Once a transient cause of VH, such as a UTI, exercise-induced haematuria or menstruation, has been excluded, the next step is generally urological referral. The urologist will perform cystoscopy and imaging as appropriate.

Many urology departments now have haematuria clinics where patients can be referred under the two-week wait rule.

These clinics often have locally drawn up guidelines regarding what investigations should be performed by the GP on referral, for example, MSU and urine cytology, so it is important to check local protocols.

One study that looked at the diagnoses for almost 2,000 patients referred to a UK haematuria clinic showed 61 per cent had no basis found for their haematuria, 12 per cent had bladder cancer, 13 per cent had UTI and 2 per cent had stones. Kidney and upper tract tumours were noted in <1 per cent.3

Patients with significant blood loss or with clot retention should be referred for emergency admission.

One exception to urology referral in the first instance of VH would be a young patient (<40 years) presenting with cola-coloured urine and a concomitant URTI. Glomerulonephritis would be a distinct possibility and a nephrology referral would be appropriate.

Long-term monitoring
After negative urological investigation, patients may still require ongoing monitoring in primary care due to the uncertain aetiology of their haematuria.

They should be monitored for persisting LUTs, recurrence of VH, proteinuria, significant falling of eGFR and hypertension. Further urology or nephrology evaluation may be needed.

  •  Dr Porter is a salaried GP in Rochford, Essex
Possible causes of visual haematuria
  • UTI
  • Renal tract stones
  • Exercise-induced haematuria
  • Menstruation
  • Urinary tract malignancy
  • Glomerulonephritis
  • Anticoagulant treatment
  • Schistosomiasis
  • Trauma

References

1. Renal Association and British Association of Urological Surgeons. Joint Consensus Statement on the Initial Assessment of Haematuria, 2008, available at www.renal.org

2. NICE. Referral Guidelines for Suspected Cancer. 2005 Online: www.nice.org.uk

3. Khadra MH, Pickard RS, Charlton M et al. A prospective analysis of 1,930 patients with haematuria to evaluate current diagnostic practice. J Urol 2000; 163(2): 524-7.

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