Red flag symptoms: Haematuria

This symptom should prompt a full assessment of the patient, says Dr Louise Jourdier.

Haematuria is a symptom that should always prompt a thorough assessment. While there are several relatively benign causes, identification of any of the above red flags should lead you to suspect the more sinister diagnoses of inflammatory renal disease and malignancy.

Red flag symptoms
  • Painless macroscopic haematuria
  • Symptomatic microscopic haematuria in absence of UTI
  • Age >50 years
  • Abdominal mass on examination

History and examination
Patients presenting with haematuria should be asked about symptoms of one of the most likely causes, a UTI. Symptoms of frequency, urgency and dysuria point to this diagnosis.

Haematuria presenting with abdominal pain 'from loin to groin' is classical of renal calculi, and there may be a previous history of similar episodes.

On the other hand, haematuria presenting without pain raises the possibility of a bladder or renal malignancy and should prompt urgent referral.

In the absence of a UTI, microscopic haematuria associated with systemic symptoms, such as joint pains, a rash or fever, should lead you to suspect an inflammatory cause, such as systemic lupus erythematosus or Henoch-Schonlein purpura.

Consider post-infectious glomerulonephritis or IgA nephropathy if there is a history of infection. A thorough drug history will reveal any nephrotoxic medications, such as cyclophosphamide or NSAIDs. Note that warfarin is not in itself a cause of haematuria. Remember to ask about recent travel (schistosomiasis) and occupational exposure (bladder malignancy).

Examination of BP (renal disease) and abdomen (urological malignancy) are vital. Genital examination is often unhelpful although examination of the prostate is necessary if there are symptoms of prostatism. Examine the skin and joints for signs of systemic disease.

Possible causes
  • Infection (cystitis, prostatitis).
  • Tumour (renal cell, Wilms' tumour, bladder, prostate).
  • Trauma.
  • Inflammation (glomerulonephritis, IgA nephropathy, Henoch-Schonlein purpura, systemic lupus erythematosus).
  • Structural (calculi, polycystic kidney disease).
  • Haematological.
  • Surgery.
  • Toxins (NSAIDs, sulphonamides, cyclophosphamide).

Investigations
Dipstick examination will rule out other causes of red urine and may show associated proteinuria, which hints at a renal cause. An MSU should be sent for microscopy culture and sensitivity testing, and a urinary protein-creatinine or albumin-creatinine ratio obtained.

Bloods including FBC, U&Es and clotting will establish the amount of blood loss, renal function and any coagulopathy. Imaging may be required to investigate calculi, and a renal ultrasound may be performed.

Any patient with frank and painless haematuria requires urgent specialist investigation, which will involve a cystoscopy and/or a CT urogram.

Urgent referral

Urgent referral is required for:

  • All patients with painless macroscopic haematuria.
  • Patients >40 years with recurrent/persistent UTI associated with haematuria.
  • Patients >50 years with unexplained microscopic haematuria.
  • All patients with an abdominal mass thought to arise from the urinary tract.
Dr Jourdier is a part-time GP in London

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