Haematuria

Differential diagnosis of red urine (it does not always need to be blood)

Haematuria
- Red blood cells in urine (macroscopic or microscopic)
Haemoglobinuria
- From haemolysis. Classical red urine.
- Positive urine dipstick
- When urine spun in centrifuge the entire fluid will remain red – whereas whole red blood cells in urine will form a supernatant – ask the lab to spin when unsure!
Myoglobinuria
- From muscle breakdown
- Measure CK
- When urine spun in centrifuge the entire fluid will remain red
Bilirubinuria
- In obstructive jaundice
- Does not occur in haemolyisis as this produced non-soluble unconjugated bilirubinaemia which is not soluble
Other
- Beetroot
- Rifampicin, nitrofurantoin, senna all change urine color
- Porphyria

Two types
- Macroscopic (visible)
- Microscopic (non-visible)
There has been a shift towards using “visible” and “non-visible” haematuria although they mean the same thing
Macroscopic patients will tell you about it! They generally present earlier – this always needs investigation

Kidney/Glomerular:
- Glomerular
  - Thin basement membrane (TBM) in children – persistent microscopic haematuria
  - IgA nephropathy – transient macroscopic haematuria sometimes followed by persistent macrosopic haematuria
  - Alport’s syndrome – like TBM but associated with deafness, X-lined dominant in 85%, defect in IV collagen of basement membrane
  - Glomerulonephritis
- Non-glomerular
  - Tumours (RCC, Wilm’s in children)
  - Nephrolithiasis
  - Infection – including renal TB
  - Polycystic kidneys
  - Trauma – take haematuria post trauma seriously!
  - Urethral stricture
  - Renal infarction/AVM/renal vein thrombosis
  - Sickle cell
  - Drugs (NSAIDs, anticoagulants)

Bladder
- Stones
- Tumours
  - Transitional cell and squamous cell
- Infections
- Cyclophosphamide (haemorrhagic cystitis)
  - Need to heavily hydrate and give MESNA
- Benign polyps
- Schistosoma haematobium

Urethral
- Benign prostatic hypertrophy
- Prostatitis
- Urethritis – take a sexual health history
- Trauma
Transient or unknown source
- Exercise induced
- Menstruation
- Post-coital
- Over-anticoagulation (though still search for source in this case)
- Functional
- Non-specific viral illness

Presenting complaint
- How often, how much for how long?
- Only associated with voiding? When in the stream?
- Associated pain? Loin to groin? Suprapubic?
Associated symptoms
- Any obvious masses?
- Trauma?
- Previous occurrences?
- Systemic symptoms or “B type” symptoms: weight loss, fevers, night sweats
- History of anticoagulation?
- Recent infections (glomerulonephritis)?
- Recent travel (Lake Malawi – schistosoma)?
- Recent instrumentation?
Past medical history
- Stone disease, cancer, recent anticoagulation, hypertension, diabetes
Drugs history
- Anticoagulants/anti-platelets, recent chemotherapy
Social history
- Risk factors for urological malignancy: Smoking, aniline dues (fumes and chemicals), radiotherapy, immunosuppression, schistosoma
Family history
- Deafness (Alport’s), general renal disease, TB contacts

Urine
- Urine dip
  - Even if negative but patient reports macroscopic urine take it seriously
- MC and S
  - Consider sending for ova if Schistosoma is suspected, red cell casts insinuate glomerular disease
- Urine cytology
Bloods
- U+Es, creatinine (?renal damage)
- FBC (?chronic disease, ?renal impairment), clotting, G+S
- Consider a PSA and haemoglobin electrophoresis
Imaging
- Renal tract USS and/or CT
  - CT pre and post contrast is preferable
Cystoscopy
- Cystoscopy is nearly always warranted: imaging does not allow for true luminal visualisation (as well as need for biopsies or ability to give treatment locally)
Renal biopsy
- If glomerulonephritis suspected

Depends on cause
Urgent referral for:
- Anyone with macroscopic haematuria
- Anyone over 50 with persistent microscopic haematuria

Glomerular lesions are more likely if: proteinuria, red cells casts, renal impairment or hypertension.
If microscopic haematuria remains unexplained then as long as patient’s symptoms remain stable an annual review with a urine dip, blood pressure check and U&Es is reasonable (can be done by GP)
Some patients depending on risk will require annual cystoscopy