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Haematuria (Blood in the Urine)

What is Haematuria (Blood in the Urine)?

Haematuria is defined as the presence of blood in the urine. It can either be seen with the naked eye (macroscopic) or only detected with a urine dipstick or a microscope (microscopic). It must be taken seriously and be investigated, as occasionally it can be due to a cancerous cause.

What are the causes of the bleeding?

Some benign causes

  • Urinary tract infections

  • Urinary tract stones

    • If there is a stone obstructing the kidney, then there may be pain associated with the bleeding (painful haematuria).

  • Benign enlargement of the prostate (BPH)

  • Prostatitis (inflammation of the prostate)

  • Glomerulonephritis (inflammation in the kidney)

  • Trauma

    • Recent bladder procedure or instrumentation.

    • Urinary tract damage either from blunt or sharp trauma.

  • Non-infective cystitis (inflammation of the bladder)

  • Radiation cystitis.

  • Haemorrhagic cystitis (can be caused by certain medications like cyclophosphamide).

  • Urethritis (inflammation of the urethra or the tube that empties the bladder to the outside)

  • Benign kidney tumour (e.g. angiomyolipoma)

Malignant (cancerous) causes

  • Bladder cancer

  • Kidney cancer

    • The 2 common types of kidney cancers are renal cell carcinoma (RCC) and transitional cell carcinoma (TCC).

    • Ureteric (tube that drains the kidney to the bladder) cancer

Prostate cancer does not usually present with haematuria.

Certain blood-thinning medications (eg. warfarin) can precipitate blood in the urine. In this situation, the underlying cause of the bleeding would still need to be looked for.

What are the symptoms?

Some patients are completely symptom-free, especially if the blood is only detectable with a urine dipstick or a microscope. Some associated symptoms can be:

  • Pain in the flank (often indicates kidney obstruction either from a stone or a blood clot)

  • Symptoms associated with infection:

    • Mild bladder infection: burning when passing urine, frequent urges to pass urine, cloudy or smelly urine.

    • More severe kidney infection: high fevers, shakes and chills, flank pain.

  • Symptoms associated with heavy blood loss:

    • Dizziness or light-headedness especially when standing up from a sitting position.

    • Pale.

    • Fast heart beat.

    • Urinary retention (inability to pass urine): If the blood forms clots in the bladder, they can block the bladder outlet and the patient will have problems passing urine.

What can be mistaken for haematuria?

  • Menstruation – the bleeding from a period can sometimes be mixed in with urine and be confused as haematuria.

  • Rectal bleeding – bleeding from the rectum can drip into the toilet bowl and get mixed in with urine.

  • Heavy exercise or physical exertion can cause myoglobinuria (muscle breakdown product in the urine) and cause the urine to appear red or brown in colour.

  • Medications that cause red urine:

    • Antibiotics like nitrofurantoin, sulfamethoxazole.

    • Anti-tuberculosis drugs (rifampicin).

    • Parkinson’s drugs (levodopa, methyldopa).

    • Food that turn urine red:

      • Beetroot, rhubarb, blackberries.

What are the investigations?

Urine test

  • A mid stream urine sample is sent for microscopy, and cultured for bacteria (infection). The bacteria is then tested for its susceptibility to different antibiotics.

  • The microscopy can also tell the shape of the red blood cells and infer whether they originate from the kidney or lower down the urinary tract (eg. bladder).

  • Microscopy can also look for cancer cells (cytology) and 3 urine samples are collected over consecutive days for this test.

Blood test

  • A full blood count is done to check how much blood the patient has lost and whether a blood transfusion is needed.

  • Other blood tests look at kidney function, calcium levels (if there is a kidney stone), blood electrolyte levels and blood clotting tests.

Radiological imaging

  • Ultrasound or CT scan to look for signs of infection, stones, kidney obstruction, cancer and anatomical abnormalities.

Flexible Cytoscopy

  • Cystoscopy is the examination of the inside of the bladder and urethra with a special viewing camera.

  • Done under local anaesthesia.

  • Essential because an ultrasound or a CT scan cannot accurately pick up bladder wall abnormalities such as a bladder tumour.

  • Fast and safe; an outpatient procedure.

What are the treatments?

Most of the time, the bleeding is not severe. If the investigations are all negative, the patient will not need any further treatment, other than routine urine checks in the future.

Treatment is aimed at stabilising the patient and treating the cause of haematuria found.

Stabilising the patient

  • May need to be admitted to a hospital for intravenous fluid or a blood transfusion if the bleeding is severe.

  • A catheter may be inserted to drain the bladder if the patient is not able to pass urine because of blood clots blocking the bladder outlet

    • The blood clots will have to be evacuated via the catheter. Sometimes this may be done in the operating theatre.

    • Then a continuous bladder washout system is put in place to steadily trickle in sterile fluid into the bladder via the catheter, and at the same time drain the bladder. This ensures clots do not reform in the bladder.

  • If the bleeding is coming from the kidney and it does not stop after conservative management,

    • An embolization (artificially clotting off) of the bleeding vessel can be done by a radiologist.

    • Very rarely, the kidney may have to be removed surgically.

Treating the cause

  • Urinary tract infection:

    • In mild cases, a course of oral antibiotics is given. In severe cases, antibiotics through a vein may be needed.

  • Urinary tract stone:

    • Depending on the size of the stone, it may be too big to spontaneously pass and the patient would surgery to remove the stone.

  • Benign enlargement of the prostate:

    • A medication can be prescribed to shrink the prostate and also prevent future bleeding (5 alpha reductase).

    • If this fails, a transurethral resection of the prostate (TURP) surgery is often effective in controlling the bleeding.

  • Glomerulonephritis (inflammation of the kidney):

    • If this is suspected, the patient will be referred to a nephrologist (a kidney physician) for further investigations as sometimes this may lead to chronic kidney failure.

  • Kidney cancer:

    • Often, the kidney would have to be removed surgically (radical nephrectomy).

    • If the cancer is small, a partial nephrectomy can be done, whereby only the cancerous lump is removed and the rest of the kidney is preserved.

  • Bladder cancer:

    • The bladder cancer is first resected via a cystoscopy procedure and the specimen is analysed to see how aggressive the cancer is. Sometimes, a chest x-ray and a CT scan may be done to see if the cancer has spread beyond the bladder.

    • If the bladder cancer is still in the early stages and has not invaded deep into the bladder wall, the treatment options include:

      • Routine surveillance with cystoscopy.

      • Bladder instillation of medications to control the cancer cells. Examples of such medications are BCG and Mitomycin. See bladder instillation therapy.

    • If the bladder cancer has invaded deep into the bladder wall but not beyond the bladder, then major surgery to remove the bladder may be done.

    • In advanced cases where the cancer has spread beyond the bladder, chemotherapy is usually administered.