A7. Haematuria and its evaluation

Haematuria refers to the presence of blood in the urine. We distinguish between microscopic haematuria, when the concentration of blood is too low to be macroscopically visible, and macroscopic haematuria (also called gross haematuria), where the concentration is so high that the urine is visible coloured red. Haematuria is defined as the presence of > 3 RBCs per field of view at 400x when examining a urine sample under the microscope, or by it's detection by laboratory methods.

Haematuria may be a sign of kidney or urinary tract pathology, including glomerulonephritis, urinary tract infection, and bladder cancer. In many, however, haematuria is transient or no underlying pathology can be found.

Severe gross haematuria, especially when there is concurrent urinary retention or voiding of blood clots, is a urological emergency as it may cause bladder tamponade.

Etiology

We distinguish two types of haematuria, glomerular haematuria and nonglomerular haematuria. Glomerular haematuria is secondary to glomerular disease. Nonglomerular haematuria is much more common.

• Glomerular haematuria - due to glomerulonephritis
  • Lupus nephritis
  • IgA nephropathy
  • Other glomerulonephritides
• Nonglomerular haematuria
  • Bladder cancer
  • Kidney cancer
  • Urinary tract infection
  • Urolithiasis
  • Benign prostatic hyperplasia

Gross haematuria:

• Urological surgery
• Haemorrhagic cystitis
• Urothelial carcinoma

Classification

Macroscopic haematuria, also called macrohaematuria or gross haematuria, is the name of haematuria where the reddish colour change of the urine is visible to the naked eye. This is due to a high concentration of blood per unit urine.

Microscopic haematuria, also called microhaematuria, where the urine is mixed with so little blood that it cannot be seen macroscopically but it can be measured on biochemical tests.

• Origin of bleeding according to which part of the urine stream which is bloody
  • Initial part (initial haematuria)
    • Anterior urethral bleeding
  • Terminal part (terminal haematuria)
    • Posterior urethral bleeding
    • Bladder neck bleeding
    • Trigone bleeding
  • The whole stream (total haematuria)
    • Bleeding above the level of the bladder

Clinical features

Aside from severe haematuria being macroscopically visible, there are rarely any clinical features. Haematuria is rarely severe enough to cause anaemia. If due to glomerulonephritis, there may be oedema and hypertension, called nephritic syndrome.

Diagnosis and evaluation

The gold standard is microscopic evaluation of the urine, with 3 or more RBCs per high-power field usually being thought of as pathological. A urine dipstick test can also be used to semiquantitatively evaluate haematuria.

Glomerular and non-glomerular haematuria have some differing features. Glomerular haematuria usually has RBC casts in the urine, as well as dysmorphic RBCs in the urine. These dysmorphic RBCs have blebs on the surface and irregular morphology. In case of glomerular disease, there is often also concomitant proteinuria. RBC casts are absent for non-glomerular haematuria, and the RBCs in this type have normal morphology.

Other causes of bleeding, like menstruation and haemorrhoids, should be excluded. To rule out transient microhaematuria, microhaematuria should be confirmed with a second analysis after 1 month.

Because malignancy may be an underlying cause, patients with otherwise unexplained macrosopic haematuria must be thoroughly evaluated for malignancy. In Norway, referral for malignancy evaluation for microscopic haematuria is indicated if there is 2+ or more on the urinary dipstick test (or > 2 RBCs per field of view on microscopy) on three separate tests with 1 month in-between. The first step is usually to rule out bladder malignancy with cystoscopy.

	Glomerular haematuria	Non-glomerular haematuria
Causes	Glomerulonephritis	Papillary necrosis, stone, cystitis, kidney cancer, urothelial cancer, etc.
Colour	Cola-coloured	Red or pink
Clots	No	Sometimes
RBC morphology	Dysmorphic RBCs	Normal RBCs
RBC casts	Sometimes	No
Proteinuria	> 500 mg/day	< 500 mg/day

Management

In most cases haematuria doesn't directly require management, as it's more a sign of disease than a problematic thing in itself. The exception is severe gross haematuria, which can cause bladder tamponade. Severe gross haematuria must be managed with bladder catheterisation with a large lumen 3-way catheter to provide continous irrigation of the bladder with saline. The bladder can also be manually irrigated with a syringe. Cystoscopy may be necessary for clot evacuation and for stopping the bleeding source with cautery or ablation.

For cases which are uncontrolled despite cystoscopy, embolisation of the bleeding artery is an option, as is intravesical tranexamic acid. The last resort is cystectomy.