Haematuria indicates blood found in the urine. It may be macroscopic (visible) or microscopic (just picked up in a urine test).

 Causes

 Haematuria can be the result of many possible factors including:

 Renal (Kidney)

·      Infection (Pyelonephritis)

·      Inflammatory conditions such as glomerulonephritis

·      Calculi (Stones)

·      Malignancy (Cancer)

o   Renal cell carcinoma

o   Urothelial carcinoma (a cancer of the lining of the draining system of the kidney down to the bladder)

 Bladder

·      Infection (Cystitis)

·      Inflammatory conditions such as interstitial cystitis

·      Calculi (Stones – either bladder calculi or passing renal calculi)

·      Malignancy (Cancer)

o   Urothelial carcinoma

o   Squamous cell carcinoma, adenocarcinoma (less common)

o   Prostate cancer – with local bladder invasion

 Prostate (males)

·      Infection (Prostatitis)

·      Benign prostatic hypertrophy (BPH)

·      Malignancy (Prostate cancer)

 Investigation

All episodes of haematuria warrant further investigation, though the degree of investigation needed will vary on the severity of the haematuria and other factors (such as additional symptoms, risk factors for cancer such as cigarette smoking).

Baseline investigations

These would usually be performed by one’s general practitioner following the initial presentation and would generally include.

·      Urine m/c/s (microscopy / cultures / sensitivity)

·      Urine cytology (an assessment of the cells shed in the urine – looking for any malignant cells)

·      Imaging

o   Renal tract ultrasound

o   CT scan of the renal tract with and without contrast (usually if there are concerning features on the ultrasound or if there is a strong suspicion of specific conditions such as renal calculi or malignancy).

Detailed investigations

These would usually be carried out after a review by your urologist, following a referral by one’s general practitioner

·      Imaging

o   Renal tract ultrasound (this may sometimes need to be repeated if the original scans were substandard – not all radiology practices are of the same standard).

o   CT scan of the renal tract (this may sometimes need to be repeated to gain additional specific information that may not have been on prior scans)

o   MRI scan of the renal tract (in certain specific circumstances)

o   Nuclear medicine studies (MAG-3 scan, DMSA scan) in certain circumstances

o   PET scan (usually in the case of a confirmed finding of certain types of malignancy for additional assessment)

·      Visual assessment of the urinary tract. These are performed by your urologist and may take on different forms

o   Cystoscopy – this is a visual inspection of the bladder through the urethra. It is usually performed under a general anaesthetic in hospital as a day procedure or may require an overnight stay. Depending on if anything is found at cystoscopy, a biopsy (tissue sample) may be performed. If a larger abnormality if found, this can be resected (shaved away via the cystoscope) at the same time.

o   Flexible cystoscopy – this is a visual inspection of the bladder through the urethra performed under local anaesthetic. It is usually performed in the urologist’s rooms for certain conditions.

o   Ureteroscopy – this is a visual inspection of the ureter (the tube from the kidney to the bladder). This is performed under a general anaesthetic in hospital. A temporary ureteric stent may be required to facilitate the inspection or after, if ureteric oedema or swelling is suspected post-operatively.

o   Pyeloscopy – this is a visual inspection of the kidney performed via the bladder and ureter. This is performed under a general anaesthetic in hospital.

Treatment

Due to the various causes of haematuria, the treatments required are highly variable and are guided by the underlying diagnosis.

The treatment required may be just something minor (e.g. reassurance, a short course of antibiotics) all the way to more complex therapies (e.g. major surgery). Your urologist will explain to you along the way the different options available, based on experience and evidence-based practice.

Dr Christopher Tracey