Red flag symptoms: Haematuria

Both micro- and macroscopic haematuria may be red flag symptoms of an underlying malignancy or infection.

  • Loin pain
  • Poor urinary stream
  • Urethral discharge
  • Painless
  • Clots
  • Fever

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The history of the haematuria should be documented in detail, including duration, pain and the presence of clots.

It is helpful to assess the type of bleeding and when during micturition the haematuria occurs as this may indicate where the bleeding originates. Bright red, macroscopic haematuria is likely to be of lower urinary tract origin, whereas hazy, reddish-brown bleeding may be of renal parenchymal origin.

Renal cell carcinoma may present with haematuria

The presence of clots suggests the bleeding originates above the bladder neck.

Haematuria, which may be microscopic, may indicate infection, the presence of renal calculi, non-infective inflammatory conditions of the kidney (nephritis), malignancy, polycystic kidneys and clotting disorders.

A common cause of blood in the urine is UTI. Increased frequency or urgency, or difficulty voiding suggests infection, especially if accompanied by a fever.

Further investigations may be needed if UTIs occur frequently. Patients who present with haematuria and symptoms suggestive of a UTI should have an MSU sent for analysis.

Renal stones may also cause macroscopic haematuria, particularly when passing the renal stone. The patient may experience severe loin pain if renal stones are present.

Stones within the ureter will cause renal colic.

Haematuria is a common presenting sign for urinary tract cancer, therefore it is important to have a low threshold for referral.

Painless macroscopic haematuria in an elderly man, without systemic infection, is a red flag for malignancy. Risk factors for renal cell carcinoma or transitional cell carcinoma include: age over 40 years, smoking and history or family history of genitourinary malignancy. Prostate cancer may also cause haematuria.

Nephritis can occur at any age, but it is a common cause of blood in the urine of children or young people. Polycystic kidney disease may first present with loin pain and blood in the urine. There may be a family history of polycystic kidneys.

Blood dyscrasias and clotting disorders may also result in haematuria. Check if the patient is on warfarin. A travel history will help to identify a parasitic cause, such as Schistosoma.

A blunt or penetrating trauma to the kidney or bladder may also cause haematuria.

Possible causes

  • UTI
  • Renal stones
  • Renal/bladder carcinoma
  • Nephritis/urethritis
  • Prostatic cancer or hypertrophy
  • Polycystic kidney disease
  • Schistosomiasis
  • Trauma
  • Blood dyscrasias
  • Clotting disorders.

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