Overview

Hematuria can be simply defined as the presence of blood in urine which is indicative of bleeding along the urinary tract. According to the National Institutes of Health, it can be further defined as the presence of at least 5 red blood cells per high power field in 3 of 3 consecutive centrifuged specimens obtained at least 7 days apart.

It may occur in healthy people where occasional red blood cells are present but it may also point towards a pathological process that needs treatment.

• Hematuria can be either:
  • Macroscopic/ gross – this is when the bleeding is visible by the naked eye making urine red, pink, brown or tea coloured.
  • Microscopic – this is when the bleeding is only detectable on microscopy and/or dipstick testing.

Causes of haematuria

There are several causes of haematuria but using the mnemonic I PEE RBCS one can easily remember the important ones:

• I – Infection (Renal tuberculosis, pyelonephritis and bacterial cystitis), IgA nephropathy
• P – Polycystic kidney disease and post-streptococcal glomerulonephritis
• E – External trauma
• E – Exercise (strenuous and vigorous exercise)
• R – Renal vascular disorders and radiation
• B – Benign prostatic hyperplasia, bilharzosis, benign familial hematuria
• C – Cancer ( Renal cell carcinoma, bladder cancer and Wilm’s tumor just to name a few) , congenital anomalies, coagulopathies
• S – Stones ( Urinary tract calculi)

Additional causes not included above are:

• Recent urological interventions such as bladder catheterization and prostate biopsy
• Pseudo-haematuria as seen in menstruation and recent intercourse
• Sickle cell disease
• Henoch schonlein purpura
• Drugs and toxins such as aminoglycosides, cyclophosphamide ( which is known to cause hemorrhagic cystitis), amitriptyline, diuretics, analgesics, oral contraceptives, anticonvulsants, and penicillins are all known to cause haematuria.

Clinical presentation

Possible cause	Signs and symptoms
A) Macroscopic Hematuria
Infection	Fever, abdominal pain, dysuria, increased urinary frequency
IgA nephropathy	Preceding upper respiratory infection, hypertension, edema, low-grade fever, flank pain
Renal tumor	Intermittent hematuria that is associated with pain and a palpable mass in the kidney
Bladder tumor	Intermittent hematuria, not associated with pain
Calculi along the urinary tract	Loin pain, increased frequency of urination, dysuria, nausea and vomiting
Polycystic kidney disease	Family history of renal disease, abdominal pain, fatigue, malaise and breathlessness
Systemic lupus erythematosus	Gross or microscopic haematuria, proteinuria, edema, malar rash, fever, sunlight sensitivity
Benign prostatic hyperplasia	Urinary symptoms such as increased frequency and urgency, nocturia, hesitancy, dribbling
B) Microscopic hematuria
Nephrotic syndrome	Painless hematuria, periorbital edema, weight gain, oliguria
Nephritic syndrome	Painless hematuria, hypertension, oliguria, edema
Post streptococcal glomerulonephritis	Preceding throat/skin infection as well as symptoms of nephritic syndrome
Sickle cell disease	Dactylitis, chest and abdominal pain, fatigue, breathlessness and jaundice
Tumor along the urinary tract	Persistent non visible hematuria in an individual more than 40 years of age
Menstruation	Woman of reproductive age with no other symptoms
Henoch schonlein purpura	Palpable purpura, abdominal pain, arthritis, preceding upper respiratory infection
Alport’s syndrome	Gross or microscopic hematuria, loss of bilateral sensorineural hearing, eye abnormalities, edema, hypertension and a family history of renal disease

Diagnosis

History and Physical examination

Taking a concise history and performing a thorough physical exam is integral to pick out the cause of hematuria. Mentioned above are some of the signs and symptoms to look out for. In addition, one should enquire about the following in the history:

1. Try to describe the characteristics of the hematuria in detail by asking whether it is continuous or periodic, painful or non-painful
2. Previous intake of any drugs, paying attention to any that can cause hematuria
3. Urogenital instrumentation
4. Strenuous exercise
5. Menstruation
6. Family history of hematuria
7. History of trauma

While performing the physical exam focus on:

1. Blood pressure levels
2. Evaluation of edema
3. Examination of the skin to check for purpura and petechiae
4. Abdominal examination for masses
5. Ophthalmologic evaluation in familial causes such as in Alport’s syndrome

Laboratory tests

1. Urinalysis – to check for infection, proteinuria, red blood cells.
2. Urine culture – to check for infection
3. Urea/Electrolyte/Creatinine test – to check renal functioning.
4. Complete blood count – to check for infection and other hematological abnormalities such as thrombocytopenia which may cause a coagulopathy
5. Serological testing – testing the levels of complement proteins such as C3, C4 and ASO levels, anti-nuclear and anti-DNA antibody levels

Imaging

1. Renal and bladder ultrasound
2. Cystoscopy
3. Voiding cystourethrography

• A kidney biopsy may be indicated in severe cases.

Treatment

• Treatment depends on the primary diagnosis.