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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


Types of haematuria

  • 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


Causes of haematuria (from kidney to urethral tip)

  •  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)
  • Ureters
    • Stones
    • Tumours
    • Strictures
    • Urethritis
  • 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


History in haematuria

  • 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


Examination in haematuria

  • Haemodynamic status: adopt an ABCDE approach if patient unwell
  • Examine for signs of anaemia: pallor (including conjunctiva)
  • Obvious bruising or bleeding
  • Evidence of pharyngitis (GN)
  • Systemic signs
    • Arthralgia, lymphadenopathy, purpuric rashes
  • Signs of endocarditis
  • Oedema
  • Hypertension
  • Abdominal masses
    • Tumours and polycystic kidneys
  • Abdominal pain
  • Abdominal bruits if AVM suspected
  • Rectal examination for prostate


Investigations in haematuria

  • 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


Management of haematuria

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


Management algorithm for 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


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