Haematuria

Haematuria is the presence of blood or red blood cells in the urine.
Hematuria can be visible or non visible haematuria ( NVH )
Definition of microsopic haematuria varies between countries and guidelines One of the definitions is – three or greater red blood cells ( RBC’s ) per high powered field ( HPF ) on a properly collected urinary specimen in the absence of a benign cause The prevalence of microscopic haematuria is 0.9 % to 21 %- less than 1.5 % of these cases have a serious underlying pathology Some studies have shown a lower prevalence of microscopic haematuria in men Microscopic haematuria can be transient or persistent ( 3 or more consecutive samples ) Causes of transient MH include
vigorous exercise
sexual intercourse
mild trauma
menstrual contamination Microscopic haematuria can also be subdivided into
Symptomatic NVH
Asymptomatic NVH.
Upper and lower urinary tract-tumour , trauma , infection ( viral , bacterial , schistomsomiasis , TB )
Kidney-glomerular IgA nephropathy , thin basement membrane nephropathy , Alport syndrome , Posy-infectious GNephritis , mesangial proliferative GN , physical stress , local pain haematuria syndrome.
Kidney- non glomerular papillary necrosis , renal infarction , renal vein thrombosis , AV malformations / fistulas , cystic renal disease , medullary sponge kidney ,nutcracker syndromeUrinary bladder- radiation ,cystitis , stone.
prostate and urethra –Prostatitis , prostatic hyperplasia , BPH , diverticulum
malignancy-Renal cell carcinoma , TCC , SCC , urothelial cell carcinoma , prostate acinal adenocarcinoma, metastatic cancer
iatrogenic -recent endoscopic procedures ( e,g TURP ) , TRUS prostate , traumatic catherisation , radiation , indwelling ureteric stones, renal biopsies , EC shockwave therapy.
Non-visible haematuria –Investigating /managing microscopic haematuria is a clinical challenge Most cases of NVH are incidental findings Always take into account the risk factors for urothilial cancers ( see box ) NVH may have a benign cause in many particularly young women with symptoms and urinary feedings suggestive of a UTI Urine microscopy is not reliable in detecting NVH so it is not necessary to confirm NVH in laboratory Overall risk of bladder cancer is
24 % of patients with VH
4 % of patients with NVH NVH has only a 0.5 % positive predictive value for bladder cancer.
New symptomtic or asymptomatic NVH on 2 or 3 dipsticks > 1 +.
check BP U/E eGFR Check for proteinuria spot ACR or PCR MSU – exclude infection FBC if > 60 yr old.Investigations normal 
BP < 140/90 and eGFR > 60 and
No proteinuria ie PCR < 50 or ACR < 30.Cause not established
 Annual reassessment whilst haematuria persists -ie BP , eGFR , proteinuria Refer urology is patient develops visible haematuria or symptomatic NVH Refer to nephrologist if patient develops proteinuria
eGFR drops < 30 on 2 seperate ocassions
eGFR falls by > 5 over 1 year or 10 over 5 yrs. Investigations abnormal
BP > 140/90
eGFR < 60 or
Proteinuria
Visible haematuria -Visible haematuria even when transient or symptomatic may indicate a serious underlying pathology which requires further investigation. Previously any painless visible haematuria of any age was referred by 2WkUSC guideline. However as the PPV of any haematuria was 0.99 % for men < 45 and 0.22 % for women < 45 yrs the 2 WUSC referral is recommended only for people with visible haematuria age > 45 without a UTI , or persisting recurring despite treatment of UTI ( NICE )
 Patient with VH are a higher risk group for urological malignancies than those with NVH ( BMJ Best Pract )

Visible haematuria is a presenting sign in more than 66 % of urological cancer
The sensitivity of visible haematuria in revealing mlignancy is significant.
Risk factors urothelial carcinoma 
( BMJ Best Practice )
 male sex age 35 yrs and over smoking exposure to benzene , aromatic aines , carcinogens , chemotherapy or high doses of analgesics h/o
irritative voiding symptoms
chronic UTI
indwelling urinary catheter
pelvic irradiation
PATIENT INFORMATION
British Association of Urological Surgeons – blood in urine https://www.baus.org.uk/patients/conditions/2/blood_in_the_urine_haematuria/
American Urological Association – what is hematuria https://www.urologyhealth.org/urology-a-z/h/hematuria
National Institute of Diabetes and Digestive and Kidney Diseases on Hematuria  https://www.niddk.nih.gov/health-information/urologic-diseases/hematuria-blood-urine
Manchester Urology – with a video on haematuria http://www.manchesterurology.org.uk/conditions/other-conditions/blood-in-urine-haematuria
Edinburgh Renal Unit on Haematuria https://edren.org/ren/edren-info/haematuria-hematuria/
References

1. Camden CCG Haematuria pathway
2. Macroscopic haematuria  A urological approach Melisa Yeoh et al Australian Family Physician Vol 42 , No 3 , March 2013
3. The investigation of Hematuria Christian Bolenz et al Dtsch Arztebl Int 2018 Nov ; 115 ( 48 ) :801-807
4. Evaluation and Management of Hematuria Masahito Jimbo Prim Care Clin Office pract 37 ( 2010 ) 461-472
5. BMJ Best Practice Evaluation of visible hematuria
6. Brighton and Sussex New Non-visible Haematuria Pathway