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
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.
- Infection: UTI, prostatitis, schistosomiasis
- Malignancy: renal carcinoma, Wilms' tumour, bladder carcinoma
- Inflammation: glomerulonephritis, Henoch-Schonlein purpura, IgA nephropathy
- Structural: calculi, polycystic renal disease
- Genital bleeding
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
This is an updated version of an article that was first published in February 2014.
- NICE. Suspected cancer: recognition and referral. NG12, June 2015 [updated July 2017]