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Posted in ARTICLE on 12:00AM, 23 February, 2021

Getting a Handle on Hematuria

Blood in the urine or hematuria itself is rarely life-threatening. However, when it is detected or seen, it is mandatory to investigate the cause as it could indicate an underlying condition that can be serious or life-threatening.

Hematuria is the medical term for red blood cells in the urine that exceeds the amount that is normally accepted.These red blood cells in the urine can come directly from the kidney itself or anywhere in the urinary tract, such as the ureters, bladder, urethra or the prostate.

There are two main types of hematuria: gross hematuria and microscopic hematuria.

Gross hematuria is when you can visually see that the urine is reddish in colour with your naked eyes. It can be in any shades of red from tea-coloured to pink to bright red. In this type of hematuria, 1 in 4 patients may have a cause.

Microscopic hematuria means that the urine looks normal in colour to the naked eyes, but when visualised under a microscope, an increased number of red blood cells can be seen. Most of these findings are detected on a urinary dipstick, where a test strip is placed in the urine and compared to the colour changes on the bottle. The dipstick test results are not always accurate and should be confirmed with a repeat microscopic examination, before proceeding to do further tests. In this type of hematuria, 1 in 12 patients may have a cause.


Once it is confirmed that there is presence of blood in the urine, the doctor will proceed to find out what causes this condition. The common causes are:-

Urinary infections.
By far, this is the most common cause of hematuria. The patient may present with other symptoms of infection, such as pain when passing urine, increased frequency of urination, fever, and incomplete emptying of urine. Some patients may not have any of the symptoms of infection. This infection can happen anywhere along the urinary system, from the kidney, ureter, bladder, prostate or the urethra.

Urinary stones.
Urinary stones are usually asymptomatic when they are in the kidney, but they can cause hematuria. When the stone moves down the ureter, this is usually accompanied by severe back pain, radiating to the lower anterior abdomen. Usually, the patients find out that they have kidney stones through the further tests that are done because of hematuria.

Urinary tract cancers.
The importance of doing further test in patients with hematuria has to be emphasised, as they may be the earliest sign of a cancer in the urinary tract. The commonest cancers of the urinary tract that present with hematuria are bladder and kidney cancers.

Kidney diseases.
Certain kidney diseases also present with hematuria. Examples are Glomerulonephritis and IgA Nephropathy. These conditions are managed by a nephrologist.

Other conditions.
People who do vigorous exercise may experience hematuria. Some people with non-cancerous prostate enlargement can also have hematuria. It is important to know that sometimes, the urine may appear reddish because of presence of red pigments. These red pigments are usually from consumption of beetroot, red dragon fruits, food dyes or certain medications.

Unknown cause.
There will be many patients whom are confirmed to have hematuria, but no cause is found. This is called idiopathic.

In order to look for the causes listed earlier, the doctor will proceed with further tests. The findings from the tests will determine the type of treatment for the patient as there is no single treatment for hematuria. Nonetheless, not all patients will need all the test that are listed here while some may require repeated tests for better causal conclusion.

Urine tests.
There a few urine tests that will be done. These include a detailed urinalysis and urine cytology. Some cancer cells can be detected in the urine cytology test.

Blood test.
This test is to look for the health of the kidney and some blood cell abnormalities that can cause bleeding.

These are radiological imaging scans that are done to look for urinary calculi, abnormalities in the urinary tract and some cancers that are visible in the imaging. The doctor will either order for an ultrasound (US) examination or a CT-Scan with contrast, when a dye is injected into the veins.

This procedure involves insertion of a small, flexible camera into the bladder through the urethra. Sometimes, a little sedation is given. The urethra and the camera will be lubricated with a numbing agent to reduce the discomfort when the procedure is done. During the cystoscopy, the doctor will have a good look at the inner layer of the bladder and urethra. If any abnormality is seen, a biopsy will be taken. The biopsy is examined under a microscope to look for abnormal or cancerous cells.

Biopsy of the kidney.
When indicated, the doctor may advise for a biopsy of the kidney. This is usually done with the guide of an ultrasound and after injecting a numbing agent. A very small piece of kidney tissue will be taken from the kidney using a biopsy needle. This tissue will be examined under a microscope to look for the cause of the hematuria by identifying any kidney diseases.

Dr Kantha Rao is a Consultant Urological Surgeon at KPJ Rawang Specialist Hospital.

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