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Haematuria

Haematuria is the presence of blood in the urine and can vary from frank bleeding (macroscopic) to the microscopic detection of red cells.

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Table H2 Haematuria: diagnostic strategy model (modified)

Probability diagnosis

Infection

  • cystitis

  • urethritis

  • prostatitis

  • pyelonephritis

  • calculi: renal, ureteric, bladder

Serious disorders not to be missed

Cardiovascular, e.g. renal infarction

Neoplasia

  • renal tumour

  • urothelial: bladder, renal, pelvis, ureter

  • carcinoma prostate

Severe infections, e.g. infective endocarditis, kidney TB, malaria

Glomerulonephritis (e.g. post strep, IgA nephropathy)/nephritic syndrome

Kidney papillary necrosis

Other renal disease, incl. polycystic kidneys

Pitfalls (often missed)

Urethral prolapse/caruncle

Pseudohaematuria (e.g. beetroot, porphyria)

Benign prostatic hyperplasia

Trauma: blunt or penetrating

Foreign bodies

Bleeding disorders

Exercise (heavy)

Radiation cystitis

Anticoagulant therapy

Menstrual contamination

Others

All patients presenting with macroscopic haematuria or recurrent microscopic haematuria require both radiological investigation of the upper urinary system and visualisation of the lower urinary system to detect or exclude kidney pathology. Consider it as carcinoma until proved otherwise.

The key radiological investigation is the intravenous urogram (pyelogram) and then ultrasound. Common urological cancers that cause haematuria are bladder (70%), kidney (17%), pelvis or ureter (7%) and prostate (5%).

The commonest cause of glomerulonephritis leading to nephritic syndrome is IgA nephropathy.

DxT: haematuria + dysmorphic RBCs/casts + one of hypertension, proteinuria, oedema + oliguria + ↑ s. creatinine → acute nephritic syndrome

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