Hematuria – Overview
Blood in urine – known medically as hematuria – is usually not a reason for major alarm. Because blood in urine can be a sign of a serious medical condition, however, it shouldn’t be ignored. All cases of hematuria should be evaluated by a doctor who can order tests to confirm or rule out an underlying cause. There is no specific treatment for hematuria because it’s a symptom and not a specific condition. Instead, treatment is aimed at the underlying cause if one can be found. In many cases, no treatment is necessary.
What are the Types of Hematuria?
Gross Hematuria
If there’s enough blood in your urine that your urine appears pink or red or has spots of visible blood, you have “gross hematuria.”
Microscopic Hematuria
When you can’t see the blood because the amount is so small, you have “microscopic hematuria.” Only a lab test that detects blood or looking at a sample of urine under a microscope can confirm microscopic hematuria.
Pathophysiology
The etiology and pathophysiology of hematuria vary. For instance, hematuria of glomerular origin may be the result of a structural disruption in the integrity of the glomerular basement membrane caused by inflammatory or immunologic processes. Chemicals may cause toxic disruptions of the renal tubules, whereas calculi may cause mechanical erosion of mucosal surfaces in the genitourinary tract, resulting in hematuria.
What causes hematuria?
Reasons people may have blood in the urine include
- Infection in the bladder, kidney, or prostate
- Trauma
- Vigorous exercise
- Viral illness, such as hepatitis – a virus that causes liver disease and inflammation of the liver
- Sexual activity
- Menstruation
- Endometriosis – a problem in women that occurs when the kind of tissue that normally lines the uterus grows somewhere else, such as the bladder
More serious reasons people may have hematuria include
- Bladder or kidney cancer
- Inflammation of the kidney, urethra, bladder, or prostate – a walnut-shaped gland in men that surrounds the urethra and helps make semen
- Blood-clotting disorders, such as hemophilia
- Sickle cell disease – a genetic disorder in which a person’s body makes abnormally shaped red blood cells
- Polycystic kidney disease – a genetic disorder in which many cysts grow on a person’s kidneys
Who is more likely to develop hematuria?
People who are more likely to develop hematuria may
- Have an enlarged prostate
- Have urinary stones
- Take certain medications, including blood thinners, aspirin, and other pain relievers, and antibiotics
- Do strenuous exercise, such as long-distance running
- Have a bacterial or viral infection, such as streptococcus or hepatitis
- Have a family history of kidney disease
- Have a disease or condition that affects one or more organs
Signs and symptoms
By itself, hematuria rarely causes symptoms. One exception is when the bladder has so much blood in it that clots form and the flow of urine is blocked. This can cause pain at the site of the blockage in the lower pelvis. Symptoms usually come from the cause of the hematuria, and vary depending on the condition:
- Glomerulonephritis – if glomerulonephritis is not severe, it may not cause any symptoms. If symptoms appear, they can include swelling, especially in the lower extremities, reduced urination, and high blood pressure.
- Kidney or bladder infection – Symptoms depend on the site of infection, but can include intense pain on one side of the mid-back, fever, shaking chills, nausea and vomiting, pain above the pubic or bladder region, foul-smelling urine, the need to urinate more often than normal, and pain or discomfort during urination.
- Prostate infection – There can be a pain in the lower back or in the area between the scrotum and anus, pain during ejaculation, blood in the semen, and, sometimes, fever and chills.
- Tumor in the kidney or bladder – Most kidney and bladder cancers grow without causing any pain or discomfort. When symptoms develop, the most common are abdominal pain, more frequent urination and pain at the end of urination.
- Kidney stones – When a kidney stone becomes trapped in one of the ureters (the narrow tubes connecting each kidney to the bladder), it can cause severe pain in the back, side or groin, nausea, and vomiting, or painful and frequent urination.
- Bleeding disorders – bleeding disorders tend to cause abnormal bleeding throughout the body, not just into the urine. Depending on the specific bleeding problem, symptoms can include abnormal bruising, prolonged bleeding from cuts, bleeding in the skin, bleeding into the joints or gastrointestinal tract (causing black, tarry stools or bright red blood in the stool), or gum bleeding even with gentle flossing or brushing.
- Trauma – there often will be signs of traumatic injury to the body surface, such as bruises, swelling, punctures, and open wounds.
What Are the Complications Associated with Hematuria?
- Many of the causes of blood in the urine are very serious. Ignoring this symptom can have dire consequences. If the symptom is due to cancer, ignoring it can lead to an advancement of the tumors to the point that they’re no longer treatable. Untreated infections can ultimately lead to kidney failure.
- Treatment can help reduce symptoms if the cause of hematuria is an enlarged prostate. Ignoring it may lead to discomfort from needing to urinate frequently, severe pain, and even cancer.
- Ignoring hematuria when you have stones can be very painful. Prescription medications and treatments can help you pass stones. These treatments work by breaking the stones into smaller pieces.
How to diagnose and confirm Hematuria?
Testing is performed to determine the extent, severity, and persistence of blood in the urine and to identify and address the underlying cause. Generally, a health practitioner will use an initial set of tests to confirm the presence of hematuria and identify or rule out some of the more common causes. Depending on those findings, as well as the affected person’s signs, symptoms, and medical history, a more extensive workup may be done.
Laboratory Test
Urinalysis – this is typically the first test performed and the primary means by which hematuria is detected or confirmed. It consists of visual and chemical examinations that can identify gross hematuria based upon the color of the urine and by a positive finding on a chemical test strip. If there are abnormal findings, then a microscopic examination is performed. According to the American Urological Association, microscopic hematuria is defined as more than 3 red blood cells seen per high powered (microscope) field (rbc/hpf) on two of three urine samples.
Blood tests for creatinine and urea nitrogen (BUN) – performed to evaluate kidney function; these may be ordered as part of a basic metabolic panel (BMP) or comprehensive metabolic panel (CMP).
Complete blood count (CBC) – to evaluate blood cells and platelets; may be ordered as a general evaluation of health or when anemia, infection, or a blood cell abnormality is suspected.
Possible follow-up testing to further evaluate the health of the kidneys and their function:
- Urine protein or urine albumin (microalbumin)
- Estimated glomerular filtration rate (eGFR) and/or rarely a creatinine clearance
- Cystatin C – may be used as an alternative to the blood creatinine test and to calculate eGFR
- Urine culture – performed to identify a bacterial infection when suspected
- Urine cytology – performed to look for and identify abnormal cells in the urine
Depending on initial test results, as well as your signs, symptoms, physical examination and medical history, some other tests may be ordered to help further investigate the underlying cause of blood in your urine. Some examples include:
- Kidney stone analysis – to evaluate the composition of a kidney stone that has been passed into the urine; this test is performed on the stone itself.
- Bleeding disorder tests – including coagulation tests such as PT and PTT
- Sickle cell tests – to determine if the source of hemoglobinuria is sickle cell disease
- Hemoglobinopathy evaluation – to identify other inherited disorders affecting red blood cells
- Autoantibody testing, such as ANA, for autoimmune disorders
- Prostatic specific antigen (PSA) – to help identify prostate cancer
- Kidney biopsy – sometimes used to help determine the nature and extent of structural damage to a kidney
Non-Laboratory Tests
Imaging tests and other procedures are sometimes performed to identify abnormalities, kidney damage, kidney obstructions, tumors, and cancers. Examples include:
- Cystoscopy
- Abdominal ultrasound
- CT scan
- Magnetic resonance imaging (MRI)
- Voiding cystourethrography
- Radionuclide studies
What is the Treatment for Hematuria?
Management of hematuria depends on the underlying cause. It varies from administering medications to performing surgery. Treatment ranges from antibiotic therapy to surgery, depending on the underlying cause as mentioned below
- Benign prostatic hyperplasia (BPH) – Avoid unsuitable foods/beverages/over the counter medications. Medications such as terazosin, tamsulosin, alfuzosin, finasteride or dutasteride are generally prescribed. Two drugs are generally used, singly or in combination. If ineffective, endoscopic surgery may be carried out
- Kidney and bladder stones – Procedures to break /remove the stones may be necessary
- Kidney disease – Treated as necessary. May involve dialysis if there is kidney failure
- Medications that induce hematuria (such as aspirin, clopidogrel, quinine may need to be discontinued
- Trauma-induced hematuria – Treated according to the problem ranging from rest to surgery
- Urinary tract blockages – Removal of the blockage
- Infection-induced hematuria – Medications
- Cancer caused hematuria – Radiotherapy, chemotherapy, and surgery
How Can I Prevent Hematuria?
Preventing hematuria means preventing the underlying causes:
- To prevent infections, drink plenty of water daily, urinate immediately after sexual intercourse, and practice good hygiene.
- To prevent stones, drink plenty of water and avoid excess salt and certain foods like spinach and rhubarb.
- To prevent bladder cancer, refrain from smoking, limit your exposure to chemicals, and drink plenty of water.