17 Dec


Hematuria is the presence of blood in the urine. It is one of the common conditions in urological practice and accounts up to 20% of all cases. This condition is closely related to malignancy and requires further investigation.

Hematuria can be classified as microscopic and macroscopic. Recent terms include non-visible and visible.



  • Urothelial cell carcinoma (UCC) of the bladder
  • Renal cell carcinoma (RCC)
  • Occasionally prostate cancer

Infection/ Inflammation

  • Urinary tract infections (UTI)
  • Other infections such as tuberculosis

Calculous disease

  • Renal
  • Ureteric
  • Bladder
  • Most stones are asymptomatic even in large staghorn calculi

Other causes

  • Vigorous Exercise
  • Haematological diseases
  • Chemotherapy and radiotherapy
  • Drugs
  • Renal disease such as nephrotic syndrome
  • Benign prostatic hyperplasia (BPH)



Besides the general approach of history taking, questions with specific symptoms or signs of hematuria should be obtained.

Physical examination

  • External features suggesting a renal disease
  • Signs of anaemia
  • Abdominal or pelvic mass
  • Digital rectal or vaginal examination for any obvious mass


Blood tests

  • Full blood count to detect anaemia and infection
  • Renal profile for renal impairment or damage

Urine tests

  • In an emergency setting, a dipstick is reasonable to suggest any infection or hematuria. If positive, a sample should be sent for UFEME. This test can detect possible cast, leucocyte and red blood cells.
Urine cytology
  • This test is used in detecting malignancy. However, it is best at detecting poorly differentiated tumours and carcinoma in-situ with low sensitivity and specificity for low-grade tumours.

Imaging and invasive procedures

Most investigations depend on the location of possible pathology. It varies from imaging to endoscopies.

Lower urinary tract

  • Flexible cystoscopy – cheap, easy access and good visualisation.
  • Rigid cystoscopy – Used after a positive flexible cystoscopy. It can be used for obtaining sample and therapy (i.e. a bladder tumour)

Upper urinary tract


  • It remains one of the initial and non-invasive imaging modality. It is use to detect suspicious intra-abdominal mass and renal abnormalities such as mass or parenchymal disease. However, it is not suitable for small lesions within the collecting system.

Intravenous urography (IVU)

  • The radiograph can aid in detecting solid objects within the ureter and renal pelvis. The visualisation is limited to differentiate cystic lesions.

CT Urography

  • This imaging is important in evaluating the collecting system. It is able to detect abnormalities in the renal and other parts of the system. Small stones could be better detected with the slim slice cut of the newer generation CT.


  • Depends on the cause
  • Tumours of the collecting system should be evaluated for resectability, operability and metastases.
  • The complications from this tumour should be monitored and treated accordingly
  • Symptomatic treatment especially in advanced diseases





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