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Hematuria
Overview
Hematuria is the presence of blood, specifically red blood cells, in the urine. Whether the blood is visible only under a microscope or visible to the naked eye, hematuria is a sign that something is causing bleeding in the genitourinary tract: the kidneys, the tubes that carry urine from the kidneys to the bladder (ureters), the prostate gland (in men), the bladder, or the tube that carries urine from the bladder out of the body (urethra).
Bleeding may happen once or it may be recurrent. It can indicate different problems in men and women. Causes of this condition range from non–life threatening (e.g., urinary tract infection) to serious (e.g., cancer, kidney disease). Therefore, a physician should be consulted as soon as possible.
Types
There are two types of hematuria, microscopic and gross (or macroscopic). In microscopic hematuria, the amount of blood in the urine is so small that it can be seen only under a microscope. A small number of people experience microscopic hematuria that has no discernible cause (idiopathic hematuria). These people normally excrete a higher number of red blood cells.
In gross hematuria the urine is pink, red, or dark brown and may contain small blood clots. The amount of blood in the urine does not necessarily indicate the seriousness of the underlying problem. As little as 1 milliliter (0.03 ounces) of blood will turn the urine red.
"Joggers hematuria" results from repeated jarring of the bladder during jogging or long-distance running.
Reddish urine that is not caused by blood in the urine is called pseudohematuria. Excessive consumption of beets, berries, or rhubarb; food coloring; and certain laxatives and pain medications can produce pink or reddish urine.
Incidence
Hematuria occurs in up to 10% of the general population.
Causes
Many conditions are associated with hematuria. The most common causes include the following:
• Benign prostatic hyperplasia (BPH) in men over 40
• Kidney and bladder stones
• Kidney disease
• Medications (e.g., quinine, rifampin, phenytoin)
• Trauma (e.g., a blow to the kidneys)
• Tumors and/or cancer in the urinary system
• Urinary tract blockages
• Viral infections of the urinary tract and sexually transmitted diseases, particularly in women
There are rare diseases and genetic disorders that also cause hematuria. Some of these are:
• Sickle cell anemia (inherited blood disorder)
• Systemic lupus erythmatosus (chronic inflammatory disorder of connective tissue)
• von Hippel-Landau disease (hereditary disease in which benign tumors form on the spinal cord, kidneys, testicles, and other organs)
Signs and Symptoms
In many cases, blood in the urine (gross or microscopic) is the only sign of a disorder. In others, a variety of symptoms, such as the following, may be present.
• Abdominal pain
• Decreased urinary force, hesitance, incomplete voiding
• Fever
• Frequent urination (polyuria)
• Pain during urination (dysuria)
• Pain in the flank or side
• Urinary urgency
Diagnosis
Classification
Bleeding is classified by when it occurs during urination, which may indicate the location of the problem.
• Onset of urination (initial hematuria)—urethra or prostate (men)
• Throughout urination (total hematuria)—bladder, ureter, or kidneys
• End of urination (terminal hematuria)—bladder or prostate (men)
Symptoms may indicate the site and/or cause of bleeding:
• Abdominal pain—inflammation of the kidney or ureter caused by trauma, infection, or tumor
• Decreased urinary force, hesitance, or incomplete voiding—lower urinary tract, benign prostate hyperplasia, tumor
• Fever—infection, typically of the kidney or ureter
• Pain in the flank—kidney trauma or tumor
• Urinary urgency, pain, or frequency—bladder cancer
The physician takes a complete personal and family medical history. The personal history can provide useful information:
• Drinking and smoking
• Exposure to toxic substance dating back 25 years or more
• History of kidney stones
• Injuries and infections
• Recent and past drug use
• Recent illness
• Urinary habits
The family history may reveal inherited predispositions to kidney stone disease, sickle cell anemia, von Hippel-Lindau disease, or another genetic disorder associated with hematuria.
A thorough physical examination is performed, with emphasis on the urinary tract, abdomen, pelvis, genitals, and rectum.
Tests
In cases of suspected microscopic hematuria, a sample of the patient's midstream urine is applied to a chemically treated strip. The chemical changes color if blood is in the urine. The intensity of the color indicates the amount of blood present. This test (called a dipstick test) is performed in the doctor's office.
A positive result warrants examination of the urine under the microscope to look for the presence of cancer cells (urine cytology). A urine culture may be grown to check for various infections. The tests may be repeated on a 24-hour collection of the patient's urine, and a blood chemistry workup may be ordered.
Cystourethroscopy, or cystoscopy, is performed when the cause of gross or microscopic hematuria cannot be identified. Local anesthesia is given, and a small, rigid or flexible fiber-optic instrument is inserted into the urethra. The physician can visually inspect the urethra, bladder, and prostate through the cystoscope. The procedure takes about 10 minutes. Some patients experience minor short-term discomfort with urination or slight spotting of blood over the next couple of days.
Intravenous pyelogram (IVP) is a special x-ray procedure in which a colorless dye containing iodine is injected into a vein in the patient's arm. The dye collects in the urinary system and provides enhanced contrast for a series of x-rays taken over 30 minutes. This produces a better image of the kidneys, ureters, and bladder and can reveal stones, tumors, blockages, and other possible causes of hematuria. After the procedure, the patient may be asked to go to the bathroom, completely empty their bladder, and return for a final x-ray.
Patients who previously had an allergic reaction to intravenous dye or to shellfish should tell their doctor before undergoing an IVP.
If these tests fail to show the cause of hematuria, ultrasound or computer-assisted tomography (CAT scan) may be ordered.
Differential Diagnosis
When no specific cause can be found, bladder and kidney stones, cancer, and other life-threatening diseases can be ruled out. The possible causes that remain include conditions that may correct themselves, or the hematuria may be idiopathic. Men over the age of 50 with no clear diagnosis should have a yearly prostate specific antigen (PSA) test to screen for prostate cancer.
Treatment
Treatment ranges from antibiotic therapy to surgery, depending on the underlying cause.
Benign prostatic hyperplasia (BPH) may be treated many ways. Eliminating foods and beverages from the diet and over-the-counter medications that irritate the prostate and cause it to swell is one option. Medication (e.g., terazosin) is often prescribed to treat BPH. When the condition does not respond to these measures, surgical removal of all or part of the gland may be recommended.
Kidney and bladder stones typically require procedures that remove or break up the stones, as well as measures to prevent their recurrence.
Kidney disease is treated according to diagnosis. In severe cases, dialysis may be necessary.
Medications (e.g., quinine, rifampin, phenytoin) that cause hematuria are discontinued.
Trauma-induced hematuria (e.g., a blow to the kidneys) is treated according to the severity of the injury, ranging from bed rest and close clinical observation to surgical repair or, in extreme cases, removal of the damaged tissue or organ.
Cancerous tumors found in the kidney, ureters, prostate, or bladder may be treated with radiotherapy, chemotherapy, and surgery.
Urinary tract blockages are treated with correction or removal of the blockage.
Viral infections of the urinary tract and sexually transmitted diseases, particularly in women, are treated with medication.
Prognosis
Prognosis differs according to the underlying condition and the patient's response to treatment.
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