Blood in the urine (haematuria) – causes and what to do

Blood in the urine – the medical term is haematuria – is one of the most common and most important complaints in urology. Sometimes the cause is harmless and temporary; at other times the blood is the first and only sign of a serious disease.

Painless blood in the urine deserves particular attention. Infections and stones usually make themselves felt with stinging, urges or pain, whereas tumours of the bladder and kidney bleed quietly, on and off, with no other symptoms. When the bleeding stops, it does not mean the problem has gone away.

What is haematuria

Normal urine contains at most a few red blood cells, invisible to the naked eye. There are two forms:

• Visible (macroscopic) haematuria – the urine is pink, red or cola-coloured. A very small amount of blood is enough to colour it.
• Non-visible (microscopic) haematuria – the urine looks normal, but a laboratory test finds more red blood cells than the acceptable number. It is usually an incidental finding.

Blood only at the start of the stream points to the urethra, blood at the end to the prostate and the bladder neck, and evenly coloured urine to the bladder, the ureters or the kidneys.

Not every red colour is blood – beetroot, some food colourings and medicines also change the colour of urine, so the first step is a laboratory test that confirms the presence of red blood cells.

Symptoms

Haematuria is itself a symptom, but the complaints that come with it point to the cause:

• stinging, frequent urination and pain low in the abdomen – most often cystitis or another infection;
• severe, wave-like pain in the lower back spreading to the groin – typical of a stone in the kidney or ureter;
• a weak stream, straining and night-time urination in men over 50 – point to an enlarged prostate;
• blood without pain and without other symptoms, especially after the age of 40–45 and in smokers – a tumour must always be ruled out;
• swelling, high blood pressure and foamy urine – a possible cause is a disease of the kidney glomeruli, which is treated by a nephrologist.

When it is urgent. Go to an emergency department or call 112 (the European emergency number) if you are passing clots and cannot pass urine, if the bleeding is heavy and you feel dizzy, if the blood appears after a blow to the abdomen or lower back, or if it comes with a high temperature, chills and pain in the lower back. These conditions cannot wait for a booked appointment.

Causes and risk factors

Blood in the urine most often appears with:

• urinary tract infections – cystitis, pyelonephritis, urethritis, prostatitis;
• stones in the kidneys, ureters or bladder;
• an enlarged prostate – the dilated blood vessels on its surface bleed easily;
• tumours of the bladder, kidney, renal pelvis and ureter, less often of the prostate;
• kidney diseases – glomerulonephritis, polycystic kidney disease, cysts;
• injury, intense physical exertion, recent catheterisation or an endoscopic procedure;
• anticoagulants – they make existing damage visible and do not remove the need for investigation.

The risk that the cause is a tumour is higher after the age of 40–45, in men, in smokers, with occupational exposure to paints and chemicals, previous radiotherapy to the pelvis and long-term use of a catheter.

Diagnosis

The consultation with Dr Penev starts with a detailed conversation: when and how the blood appears, whether there is pain, clots or a temperature, what medicines you take and whether you smoke. This is followed by a physical examination – in men, including the prostate.

The main tests are:

1. A urine test with microscopy – confirms the haematuria and shows whether there are white blood cells, protein and altered red blood cells (a sign of kidney disease); if needed, a urine culture and cytology for tumour cells are added.
2. Blood tests – kidney function, full blood count, clotting and, in men where appropriate, PSA.
3. Ultrasound of the kidneys, bladder and prostate – painless, done at the practice; it detects stones, cysts, tumours, blockage and residual urine.
4. Cystoscopy – looking at the inside of the urethra and bladder with a thin instrument under local anaesthetic. It is the only test that reliably rules out small bladder tumours; it is recommended for any visible haematuria without a clear cause and for microscopic haematuria with risk factors.
5. A CT scan with contrast (CT urography) – for visible haematuria and when a stone or tumour in the kidneys and upper urinary tract is suspected.

If there are signs of glomerular disease, Dr Penev refers you to a nephrologist.

Treatment

The cause is treated. Infections are treated with an antibiotic chosen according to the urine culture; stones with watchful waiting, medication, shock wave lithotripsy or endoscopic removal; an enlarged prostate with medication or surgery. For a bladder tumour the first step is endoscopic removal (TURBT), and for a kidney tumour, kidney-sparing or radical surgery. Dr Penev performs endoscopic and laparoscopic operations at the Department of Urology at Kaspela University Hospital (UMBAL Kaspela) in Plovdiv.

With heavy bleeding with clots and urinary retention, a catheter is placed in hospital and the bladder is washed out, and if necessary, urgent endoscopic treatment is carried out.

When to see a urologist

• with any visible blood in the urine, even once and without pain;
• with microscopic haematuria on a laboratory result, especially if you are over 40 or smoke;
• with blood in the urine that comes back after cystitis has been treated with an antibiotic;
• with haematuria while taking anticoagulants;
• with other symptoms – pain in the lower back, a weak stream, weight loss.

Where possible, the consultation and the ultrasound are done in one visit – at the practice in Plovdiv or at Vita Med Medical Centre, Karlovo.

Prevention

Not every cause can be prevented, but the risk can be reduced: do not smoke, drink enough fluids, make sure infections are fully treated, follow safety measures when working with chemicals and have a preventive urology check-up after the age of 40.

Blood in the urine is a signal the body rarely gives without a reason. Book an appointment with Dr Penev to find out where it is coming from in good time – in most patients the cause is benign, and when it is not, early diagnosis is decisive.