This document provides guidelines on evaluating and managing haematuria (blood in the urine). It defines visible and non-visible haematuria and notes that any single episode of visible haematuria or symptomatic non-visible haematuria should warrant further investigation. It recommends initial tests to check for urinary tract infection, kidney function and protein levels. Patients under 40 with visible haematuria and respiratory infection may warrant nephrology referral. Urology referral is recommended for visible haematuria of any age and non-visible haematuria over age 40. The document notes that past studies found cancers like transitional cell carcinoma in around 10% of haematuria cases, so prompt evaluation is important.

1. HAEMATURIA
RMO Teaching Whanganui DHB
Mr Christophe CHEMASLE
27th June 2013

2. Before Starting
• Macroscopic haematuria is exceptionally (=
rarely) lethal (1 personal case)
• Catheterisation is to be avoided at all cost
unless the patient is in retention
• It is OK to discharge the patient and send a
referral to the urologists (provided the
patient is stable and does not need blood
transfusion)

3. Terminology
• Visible Haematuria (VH). Referred to as ‘macroscopic haematuria’ or
‘gross haematuria’.
Urine is coloured pink or red (or, on occasion like cola in acute
glomerulonephritis). Requires consideration of rare causes of
discoloured urine (myoglobinuria, haemoglobinuria, beeturia, drug
discoloration – rifampicin, doxorubicin)
• Non-Visible Haematuria (NVH). Otherwise referred to as
‘microscopic haematuria’ or ‘dipstick positive haematuria’.
• Symptomatic Non-Visible Haematuria (s-NVH). LUTS (Lower
Urinary Tract infections eg dysuria, urgency). Flank Pain.
• Asymptomatic Non-Visible Haematuria (a-NVH). Incidental
detection in the absence
of LUTS or upper urinary tract symptoms.

4. Definition of Positivity
• Urine dipstick of a fresh voided urine sample, containing no preservative,
is a sensitive means of detecting haematuria.
• Community based urine samples sent for microscopy have a significant
false negative rate; Routine microscopy for confirmation of dipstick
haematuria is not necessary.
• Whilst the sensitivity of urine dipsticks may vary from one manufacturer
to another, significant haematuria is considered to be 1+ or greater. Trace
haematuria should be considered negative.
• There is no distinction in significance between non-haemolysed and
haemolysed dipstick-positive haematuria. 1+ positive for either should be
considered of equal significance.

5. What is significant haematuria?
• Any single episode ofVH or Any single episode of s-NVH (in absence of UTI
or other transient causes).
• Persistent a-NVH (in absence of UTI or other transient causes). Persistence
is defined as 2 out of 3 dipsticks positive for NVH.
• Transient causes that need to be excluded are: Urinary tract infection (UTI),
Exercice induced Haematuria, Menstruation
• The presence of haematuria (VH or NVH) should not be attributed to anti-
coagulant or anti-platelet therapy and patients should be evaluated
regardless of these medications.

6. Initial Investigations
• Exclude UTI and/or other transient cause.
• Plasma creatinine/eGFR.
• Measure proteinuria on a random sample. Send urine for
protein:creatinine ratio (PCR) or albumin:creatinine ratio (ACR) on a
random sample
• Blood pressure

7. Urological Referral
• All patients with visible haematuria.
• BUT patients <40 yrs with cola-coloured urine and an inter-current upper
respiratory tract infection will have an acute glomerulonephritis, and a
nephrology referral may be considered more appropriate.
• All patients with s-NVH (any age).
• All patients with a-NVH aged ≥40 yrs.

8. Nephrological Referral
• For patients who have had a urological cause excluded, or have not met the
referral criteria for a urological assessment ,
• If there is concurrent: declining GFR, Stage 4 or 5CKD, significant
proteinuria, Hypertension and <40y years old, visible haematuria with
intercurrent upper respiratory tract infection
• If criteria not met, patient should be followed in primary care

9. Long term monitoring
• Patients should be monitored for the development of:
• voiding LUTS
• visible haematuria
• significant or increasing proteinuria
• progressive renal impairment (falling eGFR)
• hypertension

11. MACROSCOPICMACROSCOPIC
14 negative (1 on Warfarin)
10 bph
7 stones (5 kidney 2 ureteric)
5 TCC
5 UTI (from which 2 urethritis and 1 prostatitis)
2 RCC
2 filling defects (1 negative URS 1 pending)
1 PCa
1 Berger’s Disease
1 post radiation cystitis
70.8 % are explained

12. MICROSCOPICMICROSCOPIC
12 negative
6 uti
5 kidney stone
3 TCC
3 interstitial cystitis
3 bph
2 referred to nephrology
1 polycythaemia
1 malignant retroperitoneal fibrosis
1 Urethral Caroncula
1 CT pending
65.7% are explained

14. TAKE HOME MESSAGETAKE HOME MESSAGE
Regardless of haematuria type, TCC
accounts for 10%
Delaying diagnosis because patient has only
has one episode of macroscopic haematuria
can have dramatic consequences

15. Thank you