Test ABC of Urology
Test ABC of Urology
Guidelines for the Management of Haematuria
Haematuria makes up a large part of a urologist's workload
All patients with either visible haematuria, non-visible symptomatic haematuria (s-nvh) or non-visible, persistent, asymptomatic haematuria (a-nvh) should be referred to a urology department for prompt investigation
The mainstay of investigation is ultrasound of the urinary tract and flexible cystoscopy usually carried out within two weeks in a one-stop haematuria clinic
Patients with significant bleeding causing urinary retention should be admitted urgently under the care of the urology team for urgent management
The main pathologies which may be discovered include tumours of the bladder, kidneys or ureters; urinary tract stones or infections. There are treatment options available for all of these
Haematuria is the presence of blood in the urine. It has urological and non-urological causes, both benign and malignant. It can also be classified into non-visible and visible haematuria. Visible haematuria means that there is sufficient blood in the urine to colour it either red or brown. Non-visible haematuria is subdivided into symptomatic and non-symptomatic types and was hitherto referred to as microscopic haematuria.
Haematuria is a very common reason for referrals to urology departments, often as an urgent problem.
Detection of non-visible haematuria in primary care is the initial step in a series of investigations, and is usually done using urine dipsticks. These grade non-visible haematuria from 'trace' to '3+'. '1+' or more is considered to be a positive reading (trace should be considered negative). There can be occasional false positive results caused by hypochlorite solutions, oxidising agents or bacterial activity (the dipstick uses oxidation of an organic peroxide by haemoglobin as its mechanism).
The Causes of Haematuria
The causes of haematuria can be grouped anatomically or aetiologically. Anatomically the source of the haematuria could be the upper tract (kidneys or ureters) or the lower urinary tract (bladder, prostate or urethra). Investigations are specifically targeted at these constituent parts: ultrasound and x-ray for the upper tract, and cystoscopy for the lower urinary tract. Aetiologically the possible causes include tumours, stones or infections in any of the constituent parts of the urinary tract (see Box 2.1). Drug abuse with ketamine is becoming an increasingly common cause of haematuria in younger patients. In either case, patients with haematuria will almost invariably require further investigation.
Urological causes of haematuria:
Cancer - most commonly transitional cell carcinoma (bladder, kidney, urethra, ureter) or renal cell carcinoma (kidney)
Stones - kidney, ureter, bladder
Urinary tract infection [UTI] (cystitis, pyelonephritis etc.)
Trauma (including instrumentation or catheterisation)
Benign prostatic hypertrophy or prostate cancer causing prostatic bleeds
The Management of Patients with Haematuria
The following groups of patients require investigation:
Any episode of visible haematuria
Any episode of symptomatic non-visible haematuria (in the absence of urinary tract infections (UTI) or other transient causes) - Box 2.2
Persistent asymptomatic non-visible haematuria (in the absence of UTI or other transient causes), i.e. 2 or 3 positive dipstick readings
Box 2.2: Transient Causes of Haematuria
Transient causes of suspected haematuria include:
Urinary tract infection: dipstick should be retaken after UTI treated