Red flag symptoms - Haematuria

Dr Suneeta Kochhar explores the red flag symptoms that may indicate a serious cause of haematuria.

Red flag symptoms

  • Red flag symptomsVisible haematuria without urinary tract infection in patients aged 45 and over
  • Visible haematuria that persists or recurs after successful treatment of urinary tract infection
  • Non-visible haematuria and either dysuria OR raised white cell count on a blood test, in patients aged 60 and over
  • Abdominal mass clinically or on imaging

Urgent referral

Macroscopic or visible haematuria (VH) may be obvious, or the urine may look like cola in acute glomerulonephritis.

It is worth considering rarer causes of red/pink urine, such as myoglobinuria, beeturia and discoloration secondary to drugs such as rifampicin.

Microscopic or non-visible haematuria (NVH) may be detected on urinary dipstick. A reading of 1+ or more is considered significant. Trace haematuria is considered negative.

Persistent haematuria may be defined by having two out of three dipsticks positive for blood. Assessment and further investigation may be necessary to rule out malignancy or underlying renal pathology.

History and examination

NVH can be symptomatic and may present with lower urinary tract symptoms. Urinary frequency, urgency, dysuria and hesitancy, as well as abdominal/pelvic pain, may be elicited in the history.

Systemic enquiry may include rashes and joint pains. Travel history and occupation may be relevant.

Haematuria may often occur in the presence of a UTI; it is recommended to repeat dipstick testing after treatment to ensure it was transient. Menstruation and exercise-induced haematuria are other transient causes.

It is important not to attribute haematuria to anticoagulant therapy, because these medications are not causative.

Physical examination should include BP and abdominal check.

Possible causes

  • Infection: UTI, prostatitis, schistosomiasis
  • Malignancy: renal carcinoma, Wilms' tumour, bladder carcinoma
  • Trauma
  • Inflammation: glomerulonephritis, Henoch-Schonlein purpura, IgA nephropathy
  • Structural: calculi, polycystic renal disease
  • Genital bleeding

Investigations

UTI should be excluded. U&Es may be necessary and protein:creatinine ratio or albumin:creatinine ratio should be measured. PSA testing should be considered in men presenting with visible haematuria.

If there is evidence of a decline in eGFR or there is already evidence of stage 4/5 chronic kidney disease, and a urological cause of haematuria has been excluded, a renal opinion is recommended.

In hypertensive patients aged under 40 years, significant proteinuria, haematuria and VH in the presence of intercurrent infection may necessitate a renal referral. Patients aged under 50 years with microscopic haematuria with proteinuria or raised serum creatinine should be referred to a renal physician; otherwise, a non-urgent referral to urology should be made.

Long-term monitoring is advisable in patients who have been referred and have negative investigations. This includes being vigilant for urinary symptoms and VH, and detecting increasing or significant haematuria, deteriorating renal function and hypertension.

NICE advises urgent referral within 2 weeks for renal tract malignancy if:

  • A patient aged 45 or over has visible haematuria without urinary tract infection
  • There is visible haematuria that persists or recurs after successful treatment of urinary tract infection
  • A patient aged 60 or over has non-visible haematuria and either dysuria OR raised white cell count on a blood test.

Routine referral should be considered in those aged 60 and over with recurrent or persistent urinary tract infection.

NICE advises urgent referral within 2 weeks for endometrial malignancy if there is postmenopausal bleeding in those aged 55 and above. Moreover, NICE advises urgent referral to exclude endometrial malignancy if there are unexplained symptoms of vaginal discharge in women presenting for the first time OR in those who have thrombocytosis OR if there is visible haematuria.

Furthermore urgent referral to exclude endometrial malignancy should be considered if there is visible haematuria and low haemoglobin OR thrombocytosis OR high blood glucose level.

  • Dr Suneeta Kochhar is a GP in Bexhill, East Sussex

Click here to take a test on this article and claim a certificate on MIMS Learning

This is an updated version of an article that was first published in February 2014.

Resources

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

One in three single-handed GPs at high-risk from COVID-19

One in three single-handed GPs at high-risk from COVID-19

A third of single-handed GPs are at high-risk from COVID-19, which could potentially...

Lack of support during the menopause leading female doctors to quit

Lack of support during the menopause leading female doctors to quit

A lack of support during the menopause has led some female doctors to consider reducing...

Viewpoint: PCNs can be at the forefront of tackling health inequlities

Viewpoint: PCNs can be at the forefront of tackling health inequlities

Dr Mark Spencer explains how the COVID-19 pandemic helped his primary care network...

GPs expected to exceed 75% flu jab uptake as NHS England reveals campaign details

GPs expected to exceed 75% flu jab uptake as NHS England reveals campaign details

The government has said it expects practices to hit a minimum 75% uptake of flu vaccination...

Red flag symptoms: Heavy menstrual bleeding

Red flag symptoms: Heavy menstrual bleeding

Possible causes of heavy menstrual bleeding (menorrhagia) include uterine and ovarian...

Details on how practices can claim COVID-19 support funding announced

Details on how practices can claim COVID-19 support funding announced

NHS England has released details on how practices can claim back additional costs...