Urology
Question 56 of 59
A 55 year old man presents to the Emergency Department complaining of visible haematuria for the last 2 weeks. He is otherwise well, with no dysuria or abdominal pain. He was treated for a lower urinary tract infection 4 weeks ago and made a full recovery with nitrofurantoin. His urine dipstick today is positive for blood but otherwise normal. His full blood count and urea/electrolyte results are normal. How should this patient be managed?
Answer:
NICE guidance recommends urgent referral of patients with visible haematuria aged ≥45 years where other indications have been ruled out, including urinary tract infections (UTIs). Where UTIs have been treated, but haematuria persists or recurs, NICE also recommend urgent referral in patients aged ≥45 years.Haematuria
Urology
Last Updated: 12th February 2021
Definitions
- Visible haematuria (VH): also called macroscopic haematuria or gross haematuria.
- Non-visible haematuria (NVH): also called microscopic haematuria or dipstick-positive haematuria.
Causes of haematuria
- Infection
- e.g. cystitis, urethritis, prostatitis
- Tumour
- e.g. urethral, bladder, prostate or renal cancer, endometrial cancer
- Trauma
- e.g. catheterisation, invasive bladder or prostate procedures
- Inflammation
- e.g. glomerulonephritis, Henoch Schonlein purpura
- Structural
- e.g. renal, bladder or ureteric calculi, polycystic kidney disease
- Haematological
- e.g. sickle cell disease, coagulation disorders, anticoagulation
- Toxins
- e.g. sulfonamides, cyclophosphamide, NSAIDs
- Other
- e.g. benign familial haematuria, exercise-induced haematuria, genital bleeding, menstruation/intercourse
Other causes of red or dark urine:
- Haemoglobinuria (in intravascular haemolysis)
- Myoglobinuria (e.g. rhabdomyolysis)
- Porphyria (urine darkens on standing)
- Bilirubinuria (in obstructive biliary disease)
- Food e.g. beetroot, blackberries and rhubarb
- Drugs e.g. rifampicin, phenazopyridine, senna
Initial investigations
- Exclude UTI and/or other transient cause.
- Urine dipstick +/- microscopy and culture.
- Plasma creatinine, electrolytes and estimated glomerular filtration rate (eGFR).
- Measure proteinuria: send urine for protein:creatinine ratio (PCR) or albumin:creatinine ratio (ACR) on a random sample (according to local practice).
- Measure blood pressure.
- FBC (anaemia) and clotting screen.
- Urine red cell morphology: dysmorphic erythrocytes suggest a renal origin.
- Cytological examination of urine.
- Consider a prostate-specific antigen test and digital rectal examination to assess for prostate cancer in men with any lower urinary tract symptoms (such as nocturia, urinary frequency, hesitancy, urgency, retention) or erectile dysfunction or visible haematuria. Refer men using a suspected cancer pathway referral for prostate cancer if their PSA levels are above the age‑specific reference range.
Further investigations:
- Ultrasound of the renal tract
- Cystoscopy
- Intravenous urography
- Renal angiography, CT scanning or renal biopsy are indicated in specific circumstances.
Indications for referral
- Visible haematuria:
- NICE guidance recommends urgent referral of patients with visible haematuria aged ≥45 years where other indications have been ruled out, including urinary tract infections (UTIs). Where UTIs have been treated, but haematuria persists or recurs, NICE also recommend urgent referral in patients aged ≥45 years.
- NICE guidance makes no recommendation about the referral of patients <45 years with visible haematuria. Studies have shown ~2% risk of bladder and 0.7% risk of renal cancer in patients presenting with visible haematuria aged 40-59 years (insufficient information on younger patients) and referral may, therefore, be appropriate in some patients <45 years with visible haematuria where other causes have been excluded.
- Non-visible haematuria:
- For non-visible haematuria, NICE recommends urgent referral for patients aged ≥60 years in the presence of either dysuria or a raised white cell count.
- NICE guidance makes no recommendation about the referral of patients <60 years with non-visible haematuria. In patients aged 40-59 years presenting with non-visible haematuria, a 0.8% risk of bladder cancer has been observed (1.6% in patients aged ≥60 years). For any urinary tract cancer, a 1.5% risk has been associated with non-visible haematuria in people aged 50-59 and of 0.4% in those aged <50 years. Due to the particularly low risk in younger people, referrals for non-visible haematuria should only be made for people ≥ 60 years where there is an increased risk of malignancy (presence of dysuria or a raised white cell count).
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
