🩺 Haematuria

Haematuria is the presence of blood in the urine, classified as visible (macroscopic) or non-visible (microscopic). It is a cardinal sign of urinary tract disease, ranging from benign infection to life-threatening malignancy. In the UK, the focus of investigation is to rule out bladder or renal cancer, especially in patients over 45-60. It can also be a presentation of primary renal disease (glomerulonephritis). Management is driven by risk stratification based on age, symptoms, and the persistence of the findings.

Distinguish between visible (macroscopic) and non-visible (microscopic) haematuria. Enquire about timing: initial haematuria suggests a urethral source, terminal suggests the bladder neck/prostate, and total haematuria implies the bladder or upper tract. Ask about 'Lower Urinary Tract Symptoms' (LUTS) like urgency and frequency, or 'storage' symptoms. Assess for pain; painless haematuria is classically associated with malignancy, whereas painful haematuria often suggests infection or stones. Screen for risk factors: smoking, occupational exposure to dyes/rubbers, and recent travel (Schistosomiasis).

Examination is often unremarkable but focuses on identifying masses or signs of systemic disease. Perform abdominal palpation for enlarged kidneys (polycystic kidney disease or tumour) or a palpable bladder (urinary retention). A digital rectal examination (DRE) is mandatory in men to assess the prostate for malignancy or benign hypertrophy. Inspect the external genitalia for local causes such as meatal stenosis, trauma, or urethral caruncles in females. Check blood pressure for signs of hypertensive nephropathy.

Urinary Tract Infection (UTI); Urothelial Malignancy (Bladder or Renal Cell Carcinoma); Nephrolithiasis (Renal Stones); Benign Prostatic Hyperplasia (BPH); Glomerulonephritis (e.g. IgA Nephropathy); Trauma or strenuous exercise.

Painless visible haematuria in adults (highly suspicious for malignancy); Visible haematuria that persists or recurs after treatment of UTI; Unexplained non-visible haematuria in patients aged ≥60 with dysuria or raised white cell count.

Urinalysis (dipstick) is the primary screening tool; automated microscopy is only used to confirm non-visible haematuria in some trusts. Baseline bloods include FBC (anaemia), U&Es (renal function), and PSA (if malignancy suspected in men). Diagnostic imaging usually involves a CT urogram or ultrasound of the renal tract. Cystoscopy is the gold standard for visualizing the bladder urothelium. If glomerulonephritis is suspected (e.g. proteinuria + haematuria), a renal biopsy may be indicated.

Visible haematuria (macroscopic) has a much higher predictive value for malignancy (approx 20%) than non-visible haematuria (approx 2%). Always rule out UTI before referring for suspected cancer, but ensure a repeat dipstick is performed after the infection has cleared to confirm resolution. 'Pseudohaematuria' can be caused by rifampicin, beetroot, or myoglobinuria.

Directly relevant to the 'Urinary tract' and 'Renal' domains. Crucial to understand the NICE NG12 referral criteria for visible and non-visible haematuria based on age.