Blood in the urine (haematuria)
What should I do if I have blood in my urine?
If you see blood in your urine, with or without symptoms of cystitis, you should contact your GP immediately for further advice
Your GP will normally investigate blood in the urine as a matter of urgency. Most GPs will perform some simple, baseline tests. You may be commenced on antibiotics to treat a presumed infection. However, if the urine test result comes back showing no evidence of infection, you will normally be referred to your local urology department for more detailed investigations using the “2-week wait” (fast-track) system.
What are the facts about blood in the urine?
- The commonest cause of blood in the urine in the UK is infection (cystitis)
- Proven blood in the urine, whether visible or non-visible (found on a urine test), should always be investigated
- 1 in 5 adults with visible blood in the urine and 1 in 12 adults with non-visible blood in the urine are subsequently discovered to have bladder cancer
- Children with blood in the urine rarely have cancer – they usually have infection in the bladder or kidney inflammation (nephritis).
- A “one-off” finding of a small trace of blood in the urine on routine testing may not be significant
- Some drugs (e.g. rifampicin, nitrofurantoin) and foodstuffs (e.g. beetroot) can turn the urine red and mimic blood in the urine
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for patients with blood in the urine. This will normally include some or all of the following:
1. A full history
Your GP will ask you questions about any recent symptoms, any associated matters (including any drugs you are taking) and will enquire about smoking habits. Exposure to industrial chemicals or to substances that may be related to bladder cancer development are also important. You should inform your GP if you are taking blood-thinning drugs (warfarin, dicoumarin) or if you take anti-platelet treatment (aspirin, dipyridamole, clopidogrel). If the bleeding is painless and associated with clots of blood in the urine, it is likely that he/she will arrange urgent referral to a urologist.
2. A physical examination
Rectal examinationA general physical examination will be performed, together with a rectal or vaginal examination. Your blood pressure may be measured as part of this examination.
3. Additional tests
The usual tests performed are:
a. General blood tests
The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function, clotting factors, prostate-specific antigen (PSA) and to check the blood cells for anaemia or other problems.
b. Urine testing
A urine test will normally be sent for infection. Your GP may commence you on antibiotics whilst awaiting the result of this test. Fresh urine may also be sent to the laboratory for microscopic examination and to look for cancerous cells. Your GP may arrange a 24-hour urine collection to measure your urine protein levels.
c. Other specific tests
Your GP may arrange an ultrasound scan of your kidneys and bladder, pictured right (or a CT scan of your abdomen) although this is usually performed in the urology department.
What could have caused the blood in my urine?
50% (half) of patients with visible blood in the urine will have an underlying cause identified but, with non-visible blood in the urine, only 10% will have a cause identified
Although there are many potential causes for blood in the urine, those most often identified are:
- Bladder infection
- Cancers of the bladder (pictured), kidney or prostate
- Stones in the kidneys or bladder
- Inflammation of the kidneys (nephritis)
- Urinary tract injuries
- Blood disorders (e.g. sickle cell disease, clotting disorders, anticoagulant and anti-platelet drugs)
- Other causes, including less common infections (e,g. TB, schistosomiasis)
What happens next?
Assessment of the cause of blood in the urine at hospital (usually in a so-called Haematuria Clinic) may not identify a definite cause but it will, normally, rule out significant causes which require further urological treatment
Your GP may decide that you do not require any further tests at this stage. In this case, you should have regular monitoring to assess the following, which may be signs that re-investigation is needed:
- the development of other urinary symptoms
- further episodes of blood in the urine
- increasing levels of protein in your urine
- progressive deterioration in your kidney function
- the development of hypertension (high blood pressure)
Your GP will arrange urgent referral to the Haematuria Clinic of your local urology unit:
- if you have visible blood in the urine in the absence of infection
- if the blood fails to clear following antibiotic treatment for urinary infection
- if you have non-visible bleeding but significant urinary symptoms
- if you have persistent non-visible bleeding and you are over the age of 40 years
This will involve a prolonged outpatient appointment when some or all of the following assessments will be performed:
- Detailed questioning about your urinary tract and any related symptoms
- A physical examination (including rectal or vaginal examination)
- Blood tests (if not already performed by your GP)
- Examination of the urine for cancer cells (if not already performed by your GP)
- X-rays or scans
This may involve one or more of the following:
- X-rays or scans
This may involve one or more of the following:
- CT scan
- ultrasound scan
- intravenous urogram (IVU)
IVU and CT scanning involve an iodine-based injection. You must inform the staff if you have a history of allergy to iodine or to previous X-ray injections.
A flexible cystoscopy
It is performed under antibiotic cover & local anaesthetic using a small, flexible telescope which allows the clinic doctor to see inside your bladder (pictured). If you have concerns about this or have experienced problems with local anaesthetic in the past, you should ask about having your examination under a brief general anaesthetic (i.e. whilst you are asleep). When your tests have been completed, the medical staff will advise you on what to do next:
If an abnormality requiring further treatment is detected, the medical staff will advise you on what treatment is necessary and what this would involve (e.g. admission for telescopic removal of a bladder tumour).
Telescopic removal of a bladder tumour(video courtesy of Dr Manoj Talwar)
If no specific abnormality is found, you should keep a careful eye on your symptoms and report any further bleeding to your GP who will be informed of the result of your assessment.