Haematuria

Introduction

Haematuria is more commonly known as blood in the urine. It can either be seen with the naked eye (macroscopic), or only detected with a urine dipstick or a microscope (microscopic). This condition must be taken seriously and investigated, as occasionally it can be due to a cancerous cause.

Causes of Haematuria

Benign causes

• Urinary tract infections.
• Urinary tract stones. If there is a stone obstructing the kidney, then there may be pain associated with the bleeding (painful haematuria).
• Benign enlargement of the prostate (BPH)
• Prostatitis (inflammation of the prostate).
• Glomerulonephritis (inflammation in the kidney).
• Trauma from recent bladder procedure or instrumentation.
• Trauma such as urinary tract damage from either blunt or sharp trauma.
• Non-infective cystitis (inflammation of the bladder)
• Radiation cystitis.
• Haemorrhagic cystitis (can be caused by certain medications like cyclophosphamide).
• Urethritis (inflammation of the urethra or the tube that empties the bladder to the outside).
• Benign kidney tumour (e.g., angiomyolipoma).

Malignant (cancerous) causes

• Bladder cancer.
• Kidney cancer. The 2 common types of kidney cancers are renal cell carcinoma (RCC) and transitional cell carcinoma (TCC).
• Ureteric cancer – the ureter is the tube that drains the kidney to the bladder.
• Prostate cancer does not usually present with haematuria.

Certain blood-thinning medications (e.g., warfarin) can precipitate blood in the urine. In this situation, the underlying cause of the bleeding will still need to be determined.

What are the symptoms?

Some patients are completely symptom-free, especially if the blood is only detectable with a urine dipstick or a microscope. Some associated symptoms can be:

• Pain in the flank – this often indicates kidney obstruction either from a stone or a blood clot.
• Symptoms associated with infection:
  • Mild bladder infection: burning when passing urine, frequent urges to pass urine, cloudy or smelly urine.
  • More severe kidney infection: high fevers, shakes and chills, flank pain.
• Symptoms associated with heavy blood loss:
  • Dizziness or light-headedness especially when standing up from a sitting position.
  • Pale.
  • Fast heartbeat.
  • Urinary retention (inability to pass urine): If the blood forms clots in the bladder, they can block the bladder outlet and the patient will have problems passing urine.

What can be mistaken for haematuria?

• Menstruation – the bleeding from a period can sometimes be mixed in with urine and be confused as haematuria.
• Rectal bleeding – bleeding from the rectum can drip into the toilet bowl and get mixed in with urine.
• Heavy exercise or physical exertion can cause myoglobinuria (muscle breakdown product in the urine) and cause the urine to appear red or brown in colour.
• Medications that cause red urine:
  • Antibiotics like nitrofurantoin, and sulfamethoxazole.
  • Anti-tuberculosis drugs (rifampicin).
  • Parkinson’s drugs (levodopa, methyldopa).
  • Food that turns urine red – Beetroot, rhubarb, blackberries.

What are the investigations?

Urine test

• A mid-stream urine sample is sent for microscopy and cultured for bacteria (infection). The bacteria are then tested for their susceptibility to different antibiotics.
• The microscopy can also tell the shape of the red blood cells and infer whether they originate from the kidney or lower down the urinary tract (e.g., bladder).
• Microscopy can also look for cancer cells (cytology) and 3 urine samples are collected over consecutive days for this test.

Blood test

• A full blood count is done to check how much blood the patient has lost and whether a blood transfusion is needed.
• Other blood tests look at kidney function, calcium levels (if there is a kidney stone), blood electrolyte levels and blood clotting tests.

Radiological imaging

• Ultrasound or CT scan to look for signs of infection, stones, kidney obstruction, cancer, and anatomical abnormalities.

Flexible Cystoscopy

• Cystoscopy is the examination of the inside of the bladder and urethra with a special viewing camera.
• A flexible cystoscopy is usually done under local anaesthesia. Sometimes a rigid cystoscopy (using a bigger rigid scope) is done under IV sedation or general anaesthesia, if it is anticipated that a bladder tumour must be resected, or if the ureter or kidney has to be inspected.
• Essential because an ultrasound or a CT scan cannot accurately pick up bladder wall abnormalities such as a bladder tumour.
• Fast and safe; an outpatient procedure.

What are the treatments?

Most of the time, the bleeding is not severe. If the investigations are all negative, the patient will not need any further treatment, other than routine urine checks in the future.

Treatment is aimed at stabilising the patient and treating the cause of haematuria found.

Stabilising the patient

• May need to be admitted to a hospital for intravenous fluid or a blood transfusion if the bleeding is severe.
• A catheter may be inserted to drain the bladder if the patient is not able to pass urine because of blood clots blocking the bladder outlet. The blood clots will have to be evacuated via the catheter. Sometimes this may be done in the operating theatre. Then a continuous bladder washout system is put in place to steadily trickle in sterile fluid into the bladder via the catheter, and at the same time drain the bladder. This ensures clots do not reform in the bladder.
• If the bleeding is coming from the kidney and it does not stop after conservative management, An embolization (artificially blocking or clotting off) of the bleeding vessel can be done by a radiologist. Very rarely, the kidney may have to be removed surgically.

Treating the cause

• Urinary tract infection:
  • In mild cases, a course of oral antibiotics is given. In severe cases, antibiotics through a drip in the vein may be needed.
• Urinary tract stone:
  • Depending on the size of the stone, it may be too big to spontaneously pass, and the patient may need surgery to remove the stone.
• Benign enlargement of the prostate:
  • A medication can be prescribed to shrink the prostate and also to prevent future bleeding (5 alpha reductase).
  • If this fails, a transurethral resection of the prostate (TURP) surgery is often effective in controlling the bleeding.
• Glomerulonephritis (inflammation of the kidney):
  • If this is suspected, the patient will be referred to a nephrologist (a kidney physician) for further investigations as sometimes this may lead to chronic kidney failure.
• Kidney cancer:
  • Often, the kidney would have to be removed surgically (radical nephrectomy).
  • If the cancer is small, a partial nephrectomy can be done, whereby only the cancerous lump is removed, and the rest of the kidney is preserved. Very small lumps can be observed in some cases.
• Bladder cancer:
  • The bladder cancer is first resected via a cystoscopy procedure and the specimen is analysed to see how aggressive the cancer is. Sometimes, a chest x-ray and a CT scan may be done to see if the cancer has spread beyond the bladder.
  • If the bladder cancer is still in the early stages and has not invaded deep into the bladder wall, the treatment options include routine surveillance with cystoscopy, and bladder instillation of medications to control the cancer cells. Examples of such medications are BCG and Mitomycin. For more information, view bladder instillation therapy.
  • If the bladder cancer has invaded deep into the bladder wall but not beyond the bladder, then major surgery to remove the bladder may be done.
  • In advanced cases where the cancer has spread beyond the bladder, chemotherapy is usually administered. Radiotherapy can also be given to control bleeding.