Haematuria is a common disorder or symptom which presents as Red discoloration of urine due to presence of blood in urine. When blood mixes with the urine, it becomes red and patient is alarmed. Such cases are encountered commonly in Outdoor, Emergency or Casualty department of any hospital, as patient immediately rushes to seek urgent medical advice. The common causes are infection that is UTI, stones in urinary tract from kidney, ureter or bladder, whereby it damages the urinary epithelium, the lining of the tract, to cause the bleeding and thus haematuria. The other causes are injury or trauma and tumors of the kidney, ureter or bladder. The patient may have painful or painless bleeding in urine which may commonly be due to stone or a cancer in the urinary tract, respectively. Therefore, the knowledge of the symptom of haematuria is of utmost importance to the public in general and medical students, doctors and experts, in particular, alike.

1. HAEMATURIA
Dr. P. KUMAR
MS ( Surg.), FLCS, FAIS, FICS,ACME
CAME, PGDHHM ( Gold Medalist )
Associate Professor
Department of General Surgery
Dr KNS Memorial Institute of Medical Sciences, Barabanki,
U.P., Bharat

2. Learning Objectives
• Introduction
• Discolouration of urine
• Definition of Haematuria.
• How to approach to a case of Haematuria.
• Clinical presentation
• Investigations in the haematuria work-up.
• Effective use of lab. and Imaging
• Management of Haematuria

3. Urinary system

4. INTRODUCTION
• Haematuria occurs when there is blood in the urine.
• Now classified as - Visible Haematuria (VH) or non-visible H. (NVH).
• Haematuria is a frequent reason for physician consultation in clinical
practice upto 08-20% of Urology consultations (Messing et al., 2006).
• Patient with haematuria should be investigated regardless of
anticoagulant therapy.
• Main focus in haematuria: is tumour detection, because haematuria,
especially if it is painless, may be due to an underlying neoplasm,
usually a Bladder or Renal tumour - Urothelial cell Carcinoma or
Renal cell carcinoma (RCC).

5. Is it Haematuria ?
Red Coloured Urine
• Haemoglobinuria / myoglobinuria
• Anthrocyanine – Beat roots & Blackberry
• Chronic Lead & Mercury Poison
• Phenolphthalein (Laxative)
• Phenothiazine &
• Rifampicin etc.

6. Discoloration of the urine
• Many drugs & foodstuffs have been reported to produce abnormal
discoloration of urine. Most frequently encountered clinically are red,
orange and brown.
• Disordered Haem in urine, produces red discoloration and gives
positive dipstick test. It is seen in porphyria, may change to  brown
or purple (with exposure to sunlight).
• Red colour of urine due to haemoglobinuria – seen in haemolytic
disorders e.g. ‘March haematuria’, classically seen in dehydrated
soldiers after prolonged marching.
• Myoglobinuria caused by Rhabdomyolysis after crush injury or
Compartment syndrome, also produces red discolouration.

7. Discoloration of the urine (Contd.)
• Several medications cause red / orange discoloration e.g. Rifampicin,
Isoniazid or Phenazopyridine. Others include - Chlorpromazine,
Thioridazine, Senna & Phenolphthalein laxatives.
• Consumption of large quantities of Beet root results in red
discoloration of urine, due to excretion of Betacyanin pigments.
• Commonly used antibiotics e.g. Nitrofurantoin & Metronidazole lead
to brown urine.
• Brown urine, due to Hyper-Bilirubinaemia is a feature of Obstructive
jaundice.

8. Definition
• Haematuria occurs – “when there is blood in
the urine”.
• Now classified as - Visible Haematuria (VH) or
non-visible H. (NVH).
• Gross Haematuria: (VH) visible to the human
eye (Red Urine)
• Microscopic Haematuria (NVH): >
3 RBC / HPF from 2 of 3 urinary sediments
without UTI / Menstruation on microscopy
(Grossfeld, 2001) - Rule out Urethral bleed.
• Photo: arrows point to WBCs surrounded by
monomorphic RBCs. 

9. Definition of positivity
• Urine dipstick Test: is sensitive to detect haematuria (if done in fresh
voided urine sample, without preservative).
• Urine R/M - for confirmation of dipstick haematuria is not necessary.
• Significant haematuria > or = 1+ (Trace haematuria considered – ve)
What is significant haematuria?
• a) Any single episode of VH.
• b) Persistent NVH (in absence of UTI or other transient causes).
*Persistence is defined as 2 out of 3 dipsticks positive for NVH.

10. Transient causes to be excluded
• UTI - A negative dipstick result for both leucocytes and nitrites.
• MSU negative for pyuria and culture.
• Exercise induced haematuria
• Menstruation.
• Rarely Myoglobinuria

11. Classification
l . CLINICAL
• Gross Haematuria
• Frankly bloody H.
• Macroscopic H.
• Red urine
• Microscopic H.
Il PATHO-PHYSIOLOGICAL
• Glomerular Haematuria
• Non-Glomerular H.

12. How to confirm Diagnosis ?
1. Gross Inspection 
2. Haematuria grading scale

13. How to confirm Diagnosis ?
3. Urine Dipstick test : 
• High false positive, so needs
confirmation by M/E
4. Urine microscopic
examination: Gold standard
• Crenated R.B.C.s can be seen
on Urine sediment
microscopy 

14. AETIOLOGY
Causes of haematuria include –
• Trauma (T) – Blunt injury abdomen, Run over accident
• Infection (I) – Pyelonephritis, Cystitis, urethritis
• Neoplasm (N) - anywhere in the urinary tract: chiefly Urothelial.
• Stones (S) – Mainly Oxalate
Other causes:
• Vascular
• Glomerular
• Interstitial disorders etc.

15. AETIOLOGY
1. Glomerular Haematuria
• Brown, tea coloured urine
• Proteinuria • deformed urinary RBCs • RBC casts
RENAL Causes: IgA nephropathy, Alport syndrome, Thin glomerular basement
membrane disease, SLE nephritis, Wegener syndrome, Good-pasture
syndrome & Sickle cell Disease.
• Important clues - presence of hypertension, reduced renal function ( eGFR)
proteinuria & presence of dysmorphic RBCs in urine sediment.
Investigations for G.H.:
• CBC • C3,C4 • Anti-streptolysin-O & Streptozyme titre
• Serum Electrolytes, BUN, S. Creat., S. albumin
• Test for Lupus • Hep B • Antinuclear cytoplasmic antibody titre

16. 2. Extra-glomerular Haematuria
• Haematuria from Upper urinary tract - Pyelonephritis, Papillary necrosis,
Nephro-calcinosis, Renal calculi esp. Oxalate stones, PUJ obstruction,
Uretero-cele & Munchausen disease
• Haematuria from Lower urinary tract – Cystitis, urethritis, Urolithiasis,
trauma, coagulopathy & heavy exercise.
• Terminal haematuria – Prostatitis, B.P.H. & Bladder neck diseases.
Nephrological referral
• Declining GFR (by > 10ml /min at any stage in last 5 years or by >
5ml /min within the last 1 year)
• Stage 4 or 5 CKD (e GFR < 30 ml/min) • Significant proteinuria
• Isolated haematuria with hypertension in those aged <40.
• Visible haematuria coinciding with inter-current URTI

17. Clinical presentation
History
• Severity –Mild, Moderate, Severe Haematuria - Brisk
• Associated with Symptoms (Pain- Dysuria) / Painless* (Could be malignant)
• Initial, Total or Terminal Haematuria
• Classic triad of Renal tumour - haematuria associated with loin pain and
palpable loin mass. Seen in < 10% patients.
• Genitourinary TB - haema­
turia associated with dysuria & frequency due to
bladder infection.
• Filariasis of retro-peritoneal lymphatics - haematuria is intermittent, often
lasting months or years and is associated with ‘milky’ or cloudy urine, the
condition is called Chyluria.

18. How to approach to a case of Haematuria
• Enquire about:
1. Timing of blood in relation to urinary stream -
• initial  Urethral pathology
• throughout the stream  Bladder or Upper Urinary tract
• terminal  Bladder neck or Prostatic pathology
2. Degree of haematuria and
3. Its frequency.

19. RED FLAGS: Risk factors for malignancy
• Smoking history
• Occupational exposure to chemicals or dyes
• Exposure to - Benzenes or Aromatic amines – Industrial worker
• History of gross haematuria
• Age – 50 years or Older
• History of urologic disorder or disease (not simple UTIs)
• History of persistent irritative voiding symptoms
• History of recurrent or chronic UTI
• Analgesic abuse
• History of Pelvic irradiation
*Source: Urology 2001;57(4)

20. Physical Examination
Vitals
Symptoms & signs
• Fever ? Infection (Pyelonephritis); HTN? (Glomerulonephritis)
• Heart: New murmur? (Endocarditis)
• Lungs: Crackles, Rhonchi ? (Good-pasture’s syndrome)
• Abdomen: Masses? (Cancer, Obstruction), Bruits? (Renal Ischemia)
• Extremities: Oedema? (Glomerulonephritis), Rashes? (HSP, CTD, SLE)
• Rectal: BPH? Nodules, Hard ? (CA Prostate),
• Tenderness present - (Prostatitis, Endometriosis)

21. INVESTIGATIONS
• Haematuria requires detailed investigation in almost all cases.
• Except young women with a proven UTI.
• Investigations include –
1. Laboratory studies
2. Imaging studies
3. Ultrasound scan (USS) of KUB (kidneys–ureters– bladder) and
4. Additional contrast imaging, if needed.

22. INVESTIGATIONS
5. Cystoscopy: Mandatory
(If no aetiology found on lab. / imaging studies).
• BPH can cause haematuria in older men, this diagnosis to be made
after exclusion of all other causes.
• Cancer detection rate depends on degree of haematuria,
• Approx. 20% in patients with VH but
• Much lower in those with NVH (<5%).

23. Laboratory Diagnosis of Haematuria
Urinalysis : Most urine samples are early morning urine, for analysis of
corpuscular elements, the “second morning urine” is more suitable and
recommended.
• Analysis should follow rapidly, preferably within 1 hour for sediment
analysis and 2 hours for dipstick testing.
Urine Cytology • Sensitivity of urine cytology for diagnosis of
urothelial CA is low and
• Negative result does not stop further testing (Rodgers et al., 2006].
• Urine cytology in hematuria does not contribute to diagnosis [Hovius
et al., 2008], which is usually made by cystoscopy or imaging.

24. Laboratory Diagnosis of Haematuria
Urine Culture - may be indicated if the sediment shows leukocytes.
Clinical Chemistry - Important to support a nephrologic diagnosis
• KFT • Coagulation profile
Cystoscopy - Flexible cystoscopy remains Gold standard for diagnosis
• Bladder Imaging to precede cystoscopy  improves diagnostic yield.
Uretero-Renoscopy
• Upper tract gross haematuria
• Unilateral haematuria
• Urothelial tumours of upper tract if imaging inconclusive & cytology
is negative.

25. IMAGING: Radiologic Diagnosis
Abdominal Radiographs • Overall sensitivity for renal and ureteral
stones is only 45–60% in multiple studies (Ege et al., 2004)
Ultrasound - suitable as first-line diagnostic test
• USG showed higher sensitivity for bladder tumours & upper urinary
tract tumours, in comparison with Excretory Urography.
• Ultrasound alone is not sensitive (19–32%) for stone detection,

26. Left Renal calculus Right Renal tumour

27. IMAGING (Contd.)
Excretory Urography ( IVU) 
• Low sensitivity (< 60%) for
renal tumours < 3 cm
• Hence, CT urography is
superior to Excretory
Urography.
Retrograde Uretero-
pyelography - with increasing
use of MDCT urography and
uretero-renoscopy, its role has
diminished significantly.

28. Computerized Tomography Scan
Non-contrast CT - Now reference standard for stone detection
• Even very-low-dose NCCT with radiation dose comparable to that of
abdominal radiographs have shown better results (Kluner et al. 2006).
CT Urography - For haematuria, overall sensitivity is 92–100% &
specificity is 89–97% (Albani et al.,2007 & Sudakoff et al., 2008)
Radiation Exposure:
• KUB = 0.2–0.7 mSv, CTKUB = 2–3 mSv, CTU = 9-16 mSv ;
• Therefore, use of CT urography should be justified by weighing
benefits versus risks and CT urography protocols should be optimized
to radiation dose.

29. Non-contrast computed tomography scan
demonstrating (a) bilateral renal calculi (b) Left ureteric calculus

30. IMAGING (Contd.)
MR Urography (MRU) -
• Advantages: it does not require ionizing radiation, has a high
contrast resolution, has good sensitivity for contrast media and
better tissue characterization than other imaging techniques.
• It is good for paediatric diseases and for evaluation of obstructive
disease (Silverman et al., 2009)
• Disadvantage: costly, technically demanding & not widely practiced.
MRU expertise is available only in specific dedicated centers.

32. Urology stack 
from top to down: (a) Monitor, (b) Laparoscopy Insufflator for CO2,
(c) Camera connector, (d) Light source (e) Video recording device.
Flexible cystoscope

33. CYSTOSCOPY

34. Management
Principles:
• ABC….
• Assessment & Initial Tt
Resuscitation & Bleeding control
• Be aware of Causes
Establishment of Diagnosis
• Cure - Definitive Treatment

35. Management
Assessment : Initial Treatment
• Severe - Haemorrhagic Shock  Resuscitation
• Restoration of Blood Volume - I.V. Fluid - (Crystalloids/Colloids)
• Blood Component Transfusion
Base line lab. Tests :
• Hb%, Hematocrit, Renal function – S. Creatinine
• Bleeding Diathesis : BT / CT, PT /PC, INR
• Activated Thromboplastin Time , Platelet Count, etc.
• Blood Cross match

36. Conservative Treatment
Bleeding Control -
Haemostyptics:
• Ethamsylate : Capillary Hge., 250 - 500 mg TDS, IV /Oral
• Tranexamic : Acid activation of Plasminogen, 500 – 1000 mg TDS
• Adrenochrome : Oxidised product of Adrenaline, 10 - 20 mg / day
• Botropase : Venom based, 1ml SOS, upto 2 to 3 times / day
• Various Combinations
Antibiotics
Assurance & Anxiolytics
I. V. Fluid
Catheterization (If Retention present) +- Bladder Irrigation

37. Be aware of Causes:
Establishment of Diagnosis
CAUSES:
1. Medical 2. Surgical / Urological
Medical:
1. Drugs 2. Bleeding Diathesis
3. Nephrolgical
• Glomerular - Cast, Proteinurea,
Dysmorphic RBCs.
• Tubulo-interstitial - Uniform round RBCs
Photo: Glomerular - Casts and
Dysmorphic RBCs (arrow) 

38. Surgical / Urological
• Tumour – Renal, Ureter ,Bladder,
Prostate
• Trauma- Iatrogenic, External
• Stone - KUB
• Infection - Tuberculosis, Filariasis,
Non-specific infections
• Vascular- Renal artery embolism,
Thrombosis, A. V. fistula
• Congenital- Adult Polycystic Kidney,
P.U.J. Obstuction

39. Investigation of Choice for Select conditions
• USG - Stone, Mass
• CECT - RCC, Polycystic Kidney, Trauma
• IVU ? - TB, TCC Upper tract
• RGU / Cystoscopy - Bladder Lesion
• Ureteroscopy - Ureter and calyx
• Renal Angiography - Vascular Causes

42. Cure –Definitive Treatment of Disease
1. Trauma – Conservative management first
• - Surgical Mgt. – Nephrectomy – Partial / Total
2. Infection – Plenty of fluids orally, Antibiotics: Initially Empirical
• - According to Urine C/S
3. Stone – If < 5 mm - Plenty of fluids orally
• - If > 5 – 10 mm - Analgesics, Tamsulosin, Syp. Stone 1 B6
• - If > 10 mm – Surgical Mgt. – ESWL, PCNL, URL, Lithotomy
4. Tumour –
• Renal: Partial or Total Nephrectomy
• Urinary Bladder: Trans – Urethral Resection of Prostate (TURBT)

43. TURBT

44. Take home message
Confirm Haematuria
• Positive Dipsticks for blood should get microscopic confirmation
• Review Urethral Bleeding
Assessment and Initial Management:
• Resuscitation & Control Bleeding
Beware of Causes : Establish diagnosis
• Top 3 Suspects are: Infection, Stones and Tumor.
• Proper evaluation, to establish cause & site of Bleeding is mandatory
Cure –Definitive Treatment of Disease

45. References
• Schwartz principles of Surgery (9th edition).
• Bailey & Love ; Short practice of Surgery (28th edition).
• Beers MH, et al., Merck Manual of Diagnosis and Therapy (18th print)
• Cohen RA and Brown RS, “Microscopic Hematuria,” New England
Journal of Medicine, 348:23, 5 June 2003.
• Grossfeld GD, et al., “Evaluation of asymptomatic microscopic
hematuria in adults: the American Urological Association best practice
policy recommendations. Part II: patient evaluation, cytology,
• Schrute D, “Beets and Urine” Pennsylvania Beet Farms, vol. 3, no. 6.