Noticed blood in your urine or been told you have microscopic haematuria?

This is a sign that should never be ignored. While often caused by common issues like infections or stones, it *always* requires proper investigation to rule out more serious underlying conditions. Getting a swift, accurate diagnosis is the key to peace of mind and effective management. Explore the information below or book a consultation to discuss your specific situation.

Understanding the Types: Macroscopic vs. Microscopic

Haematuria is primarily classified based on whether the blood is visible:

• • Macroscopic Haematuria (Visible Haematuria / Gross Haematuria): This is when the urine changes colour due to blood, appearing pink, red, brown, or 'cola-coloured'. Even a small amount of blood (as little as 1ml per litre of urine) can cause a visible colour change. The presence of blood clots usually indicates a significant amount of bleeding, often from the lower urinary tract (bladder or prostate). Visible haematuria is always considered clinically significant and requires urgent investigation.
• • Microscopic Haematuria (Non-Visible Haematuria / Dipstick Haematuria): Here, the urine looks normal in colour to the naked eye, but red blood cells are detected when the urine is examined under a microscope in the laboratory or via a urine dipstick test performed in the clinic. The standard definition is typically the presence of 3 or more red blood cells per high-power field (RBC/hpf) on microscopic analysis of a properly collected urine sample. While many cases of microscopic haematuria have benign causes or no cause is found, it still requires systematic investigation, especially in individuals with risk factors for urological cancer.

Distinction Importance: Visible haematuria carries a significantly higher risk of underlying malignancy (cancer) compared to microscopic haematuria and therefore usually triggers a more urgent investigative pathway.

What is Haematuria?: Key Points

• • Haematuria means blood in the urine – visible (macroscopic) or microscopic.
• • Visible haematuria (pink/red/cola urine, clots) always requires urgent investigation.
• • Microscopic haematuria (>3 RBCs/hpf) also requires investigation, especially with risk factors.
• • Urine tests help distinguish kidney filter bleeding (glomerular) from urinary tract bleeding (non-glomerular/urological).

Common and Significant Causes Explained

Here are some of the most frequent or important causes we consider:

• • Urinary Tract Infections (UTIs): Inflammation of the bladder (cystitis) or kidneys (pyelonephritis) caused by bacteria irritates the lining and can cause both visible and microscopic haematuria, often accompanied by pain/burning on urination, frequency, and urgency.
• • Kidney or Bladder Stones (Urolithiasis): Stones forming in the kidney can travel down the ureter causing intense pain (renal colic) and haematuria due to abrasion. Stones within the bladder can also cause irritation and bleeding.
• • Benign Prostatic Hyperplasia (BPH) (Men): An enlarged prostate can have increased blood vessels on its surface that are prone to bleeding, causing haematuria, often alongside LUTS like weak stream or frequency.
• • Prostatitis (Men): Inflammation of the prostate gland can cause haematuria, often with pelvic pain and LUTS.
• • Urological Cancers:** This is the most serious concern to rule out. Haematuria can be a sign of:
• • Bladder Cancer: Typically presents with painless visible haematuria.
• • Kidney Cancer (Renal Cell Carcinoma): Can cause haematuria, flank pain, and sometimes a palpable mass (though often detected incidentally on scans now).
• • Upper Tract Urothelial Carcinoma (UTUC): Cancer in the lining of the renal pelvis or ureter.
• • Prostate Cancer (Less Common Presentation): Advanced prostate cancer can invade the bladder or urethra causing haematuria, but it's not a typical early sign.

Kidney Diseases (Glomerular Causes): Conditions affecting the kidney's filters, such as IgA nephropathy, Alport syndrome, or thin basement membrane disease, cause microscopic (and sometimes macroscopic) haematuria, often with proteinuria. Investigation falls under Nephrology.Trauma or Injury: Direct injury to the kidneys, bladder, or urethra can cause bleeding.Medications:** Certain drugs, especially blood thinners (like warfarin, apixaban, aspirin) can increase the risk of bleeding from even minor lesions. Some other drugs can occasionally cause kidney inflammation (interstitial nephritis).Strenuous Exercise:** Intense physical activity can sometimes cause temporary microscopic or visible haematuria ("runner's bladder"), likely due to minor bladder trauma or kidney filtration changes. This is usually benign but requires exclusion of other causes first.Inherited Conditions:** Less common causes include Polycystic Kidney Disease or Sickle Cell Disease/Trait."Idiopathic" Haematuria:** In a proportion of cases, especially microscopic haematuria in younger individuals with no risk factors, no specific cause is found despite thorough investigation. Follow-up is usually still recommended.

Potential Haematuria Causes: Key Points

• • Causes range from common benign issues (UTIs, stones, BPH) to serious conditions (cancer, kidney disease).
• • Visible haematuria raises higher suspicion for malignancy than microscopic haematuria.
• • Understanding how different conditions cause bleeding helps guide investigations.
• • Thorough assessment is essential to identify the specific cause in each individual.

Key Risk Factors We Consider

Based on large studies and clinical guidelines, the following factors are known to increase the risk of finding a urological malignancy in patients presenting with haematuria:

• • Age: The risk increases significantly with age, particularly over 40-50 years old, with peak incidence in the 60s, 70s and 80s.
• • Smoking History: Current or past smoking is a major risk factor for both bladder and kidney cancer. The duration and intensity of smoking matter.
• • Type of Haematuria: Visible (macroscopic) haematuria carries a substantially higher risk than microscopic haematuria.
• • Male Gender: Men have a higher incidence of bladder and kidney cancer compared to women.
• • Occupational Exposure:** History of exposure to certain industrial chemicals (e.g., aromatic amines used in dye, rubber, paint industries) increases bladder cancer risk.

History of Pelvic Radiation:** Radiotherapy for other pelvic cancers can increase the long-term risk of secondary bladder cancer.Chronic Bladder Issues:** Long-term irritation from indwelling catheters or recurrent infections can slightly increase risk over many years.Certain Medications:** Past use of cyclophosphamide (a chemotherapy drug) or prolonged high-dose analgesic abuse (phenacetin - now withdrawn) are linked to increased risk.Family History:** A strong family history of certain urological cancers can increase individual risk.

Combining Factors: The presence of multiple risk factors (e.g., an older male smoker with visible haematuria) significantly elevates the probability of finding a malignancy and mandates a comprehensive and prompt investigation.

Low-Risk Individuals: Conversely, younger individuals (e.g., under 40), non-smokers, with isolated microscopic haematuria and no other risk factors have a very low likelihood of malignancy, although investigation is still generally warranted to exclude other causes like stones or kidney disease.

Risk Factors for Serious Causes: Key Points

• • Age, smoking history, and visible haematuria are major risk factors for underlying cancer.
• • Male gender, occupational exposures, and previous pelvic radiation also increase risk.
• • Assessment of individual risk factors helps guide the urgency and extent of investigation.
• • Low-risk individuals still require investigation but have a much lower chance of serious pathology.

Ultrasound Scan (USS) of the Renal Tract

What it is: A non-invasive scan using sound waves to create images of the kidneys and bladder. Often performed with a full bladder initially, then repeated after voiding to measure the Post-Void Residual (PVR).

Why it's done for haematuria:

• • Excellent first-line test, readily available, no radiation.
• • Good at assessing kidney size and structure, detecting larger kidney masses or cysts, and signs of obstruction (hydronephrosis).
• • Can visualise the bladder wall for significant thickening or larger tumours/stones, and accurately measures PVR.

Limitations: Less sensitive than CT for detecting small tumours, especially in the ureters or renal pelvis (the collecting system). Operator dependent. Can be limited by patient body shape.

Patient Experience: Painless procedure involving gel applied to the skin over the kidneys and lower abdomen. Requires a full bladder initially.

CT Urography (CT IVU / CT KUB with Contrast)

What it is: Considered the gold-standard imaging test for investigating haematuria, particularly visible haematuria or higher-risk cases. It uses X-rays and an intravenous iodine-based contrast dye to provide highly detailed images of the kidneys, ureters, and bladder in different phases of enhancement and excretion.

Why it's done for haematuria:

• • Excellent sensitivity and specificity for detecting small tumours in the kidneys and, crucially, the ureters and renal pelvis (Upper Tract Urothelial Carcinoma - UTUC), which are often missed on ultrasound.
• • Clearly identifies kidney and ureteric stones.
• • Provides detailed anatomical information about cysts, structural abnormalities, and signs of obstruction.
• • Images the bladder well, particularly in the delayed (excretory) phase when filled with contrast.

Procedure Phases (Typical):

1. 1. Non-Contrast Scan:** Initial scan to detect stones (which are bright white).

Nephrogenic Phase:** Scan after contrast injection when kidney tissue is enhancing (good for detecting renal masses).Delayed/Excretory Phase:** Scan several minutes later when contrast fills the collecting system (ureters, bladder), outlining their lining (good for UTUC and bladder lesions).

Considerations:** Involves ionising radiation (X-rays). Requires intravenous contrast dye, which carries a small risk of allergic reaction and can affect kidney function (blood test for kidney function is required beforehand). Not suitable for patients with severe contrast allergy or significantly impaired kidney function (MRI Urography may be an alternative).

Patient Experience: Involves lying on a CT scanner bed. An IV line is inserted for the contrast injection, which can cause a temporary warm flushing sensation. The scan itself is quick.

Example CT Urogram demonstrating its ability to detect kidney abnormalities.

Flexible Cystoscopy: The Standard Outpatient Check

What it is: The most common type of cystoscopy performed for initial haematuria diagnosis. A thin, flexible telescope with a light and camera at the end is gently passed through the urethra into the bladder.

Why it's done:

• • Provides a clear, magnified view of the entire bladder lining to look for tumours, suspicious red patches (CIS), stones, inflammation, or other abnormalities.
• • Allows inspection of the prostatic urethra (in men) and bladder neck.
• • Guides decisions about whether further procedures (like biopsy under GA) are needed.

Patient Experience: Typically performed in an outpatient clinic setting. Local anaesthetic lubricating gel is inserted into the urethra to minimise discomfort. The procedure itself usually takes only 5-10 minutes. You can usually watch the images on a screen alongside the clinician. Some mild discomfort or stinging on urination afterwards is common but usually short-lived.

A flexible cystoscope allows comfortable examination.

Rigid Cystoscopy & Biopsy / TURBT (Diagnostic Role)

What it is: Uses a straight, rigid telescope. This procedure is usually performed in an operating theatre under general or spinal anaesthesia.

Why it's done in haematuria diagnosis:

• • If flexible cystoscopy identifies a suspicious lesion or tumour requiring a tissue sample for diagnosis (biopsy).
• • Allows for better instrumentation to take targeted biopsies ('cold cup' biopsy for small lesions) or perform a Transurethral Resection of Bladder Tumour (TURBT).
• • **TURBT (Diagnostic Aspect):** While TURBT is also the *treatment* for visible bladder tumours, its initial role here is diagnostic – to completely remove the visible tumour tissue so the pathologist can determine the type of cancer and how deeply it invades the bladder wall (staging). This crucial staging information dictates further management.
• • Provides excellent visualisation and allows for more extensive examination or treatment if needed concurrently.

Patient Experience: Requires anaesthesia (GA or spinal). Usually performed as a day-case procedure but may require an overnight stay depending on the extent of resection. A temporary urinary catheter may be placed afterwards. Recovery involves some bladder irritation or bleeding for a short period.

Important Note on Scope:** This page focuses on diagnosis. While TURBT is mentioned here because it's the definitive way to get a tissue diagnosis and stage a visible bladder tumour found during investigation, detailed discussion of TURBT as a *treatment* for bladder cancer belongs on a dedicated bladder cancer treatment page.

Enhanced Cystoscopy Techniques (Blue Light / NBI)

In specific situations, particularly when looking for subtle lesions like Carcinoma in Situ (CIS) or monitoring patients with a history of bladder cancer, specialised techniques might be used alongside standard white-light cystoscopy:

• • Photodynamic Diagnosis (PDD) / Blue Light Cystoscopy:** Involves instilling a photosensitising agent (like Hexvix®) into the bladder before cystoscopy. Cancerous cells preferentially take up this agent. When viewed under blue light, the abnormal areas fluoresce bright pink/red, making them easier to see and biopsy compared to standard white light alone. Improves detection of CIS and some papillary tumours.

Narrow Band Imaging (NBI): Uses filtered light to enhance the appearance of blood vessels on the bladder surface. Abnormal tumour vasculature often appears more prominent under NBI, helping to highlight suspicious areas that might be subtle under white light.

These enhanced techniques are typically used in specialised centres or during rigid cystoscopy/TURBT when higher diagnostic accuracy for subtle lesions is needed.

Recognising Red Flags Associated with Haematuria

While all haematuria needs investigation, certain situations require more immediate medical assessment. Please seek urgent advice from your GP, NHS 111, or attend A&E as appropriate if you experience:

• • Visible Blood with Blood Clots: Passing clots often signifies more significant bleeding, frequently from the lower tract (bladder/prostate), and needs prompt evaluation.
• • Haematuria with Symptoms of Acute UTI: Such as high fever, shaking chills (rigors), severe loin pain, nausea/vomiting – this could indicate a kidney infection (pyelonephritis) requiring urgent antibiotics.
• • Inability to Pass Urine (Acute Urinary Retention): Especially if associated with haematuria (clots can block the bladder outlet). This is a medical emergency requiring immediate A&E attendance for catheterisation.
• • Haematuria Following Significant Trauma:** To the back, abdomen, or pelvis.

Haematuria Accompanied by Feeling Very Unwell:** Dizziness, faintness, extreme fatigue, or signs of severe anaemia.

What to do: For visible blood without severe symptoms, contact your GP surgery urgently for assessment and referral. For the more acute symptoms listed above (retention, severe pain, fever/rigors, feeling very unwell), attend your nearest A&E department or call 999 if necessary.

Don't delay seeking help if you experience these red flag symptoms.

Call NHS 111 for Urgent Advice 

Moving from Diagnosis to Management Plan

Once all the necessary investigations (history, examination, urine tests, blood tests, imaging, cystoscopy +/- biopsy results) are complete, I will sit down with you to discuss the findings in detail. We will establish a clear diagnosis, explaining what condition is causing the haematuria.

Based on this confirmed diagnosis, we will then formulate a personalised management plan. It's important to understand that the "treatment" isn't for haematuria itself (which is a sign), but for the specific underlying condition identified. For example:

• • If a Urinary Tract Infection is found, the treatment is antibiotics.
• • If Kidney or Bladder Stones are diagnosed, treatment might involve pain relief, hydration, medication to help pass the stone, or procedures like lithotripsy or surgery to remove them.
• • If Benign Prostatic Hyperplasia (BPH) is the main cause, options range from lifestyle changes and medication to surgical procedures targeting the prostate.
• • If Bladder Cancer is diagnosed via biopsy/TURBT, the treatment depends entirely on the stage and grade of the cancer, involving further scans, potentially more surgery, intravesical therapy (chemotherapy/immunotherapy into the bladder), or sometimes radiotherapy or removal of the bladder (cystectomy).
• • If a Kidney Tumour is found, management typically involves surgery (partial or radical nephrectomy), or sometimes surveillance or ablation for small tumours.
• • If a Glomerular Kidney Disease is suspected, referral to a Nephrologist for specialised management (often involving monitoring, blood pressure control, sometimes immunosuppression) is necessary.
• • If no specific cause is identified despite thorough investigation (common with microscopic haematuria), a plan for follow-up and monitoring will be discussed, often involving repeat urine tests and potentially imaging/cystoscopy at intervals based on risk factors.

The transition from diagnosis to treatment involves a shared decision-making process, ensuring you understand the diagnosis, the rationale for the proposed treatment, the potential benefits and risks, and alternative options.

View Key Conceptual References [Illustrative Examples - REPLACE WITH ACTUALS]

1. 1. National Institute for Health and Care Excellence (NICE). Suspected cancer: recognition and referral. NICE guideline [NG12]. 2015 (updated 2021). www.nice.org.uk/guidance/ng12 [Ref Haematuria-NICE]
2. 1. Davis R, Jones JS, Barocas DA, et al. Diagnosis, evaluation and follow-up of asymptomatic microhematuria (AMH) in adults: AUA guideline. J Urol. 2012 Dec;188(6 Suppl):2473-81. (And subsequent updates/validations). [Ref AMH-AUA]
3. 1. Loo RK, Lieberman SF, Slezak JM, et al. Stratifying risk of urinary tract cancer in patients with asymptomatic microscopic hematuria. Mayo Clin Proc. 2013 Feb;88(2):129-38. [Ref Haematuria-Risk-Stratification]
4. 1. Gravas S, et al. EAU Guidelines on Urological Infections. European Association of Urology. 2023. uroweb.org [Ref UTI-EAU]
5. 1. Babjuk M, et al. EAU Guidelines on Non-muscle-invasive Bladder Cancer (TaT1 and CIS). European Association of Urology. 2023. uroweb.org [Ref NMIBC-EAU]
6. 1. Ljungberg B, et al. EAU Guidelines on Renal Cell Carcinoma. European Association of Urology. 2023. uroweb.org[Ref RCC-EAU]
7. 1. Skolarikos A, et al. EAU Guidelines on Urolithiasis. European Association of Urology. 2023. uroweb.org [Ref Stones-EAU]
8. 1. Patient information leaflets from the British Association of Urological Surgeons (BAUS) on Haematuria, Cystoscopy, CT scans etc. www.baus.org.uk/patients/information_leaflets/ [Ref BAUS-Leaflets]

Full guidelines contain comprehensive detail for healthcare professionals.

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