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ALL / Nephrology

Haematuria

Haematuria

The management of patients with haematuria is often difficult due to the absence of widely followed guidelines. It is sometimes unclear whether patients are best managed in primary care, by urologists or by nephrologists.

The terminology surrounding haematuria is changing. Microscopic or dipstick positive haematuria is increasingly termed non-visible haematuria whilst macroscopic haematuria is termed visible haematuria. Non-visible haematuria is found in around 2.5% of the population.

Causes of transient or spurious non-visible haematuria
  • urinary tract infection
  • menstruation
  • vigorous exercise (this normally settles after around 3 days)
  • sexual intercourse

Causes of persistent non-visible haematuria
  • cancer (bladder, renal, prostate)
  • stones
  • benign prostatic hyperplasia
  • prostatitis
  • urethritis e.g. Chlamydia
  • renal causes: IgA nephropathy, thin basement membrane disease
  • thin basement membrane disease
    • hereditary nephropathy characterised by diffuse thinning of the glomerular basement membrane (GBM), leading to persistent microscopic haematuria
    • autosomal dominant with variable penetrance
    • estimated to affect 1–5% of the general population worldwide
    • excellent prognosis

Spurious causes - red/orange urine, where blood is not present on dipstick
  • foods: beetroot, rhubarb
  • drugs: rifampicin, doxorubicin

Management

Current evidence does not support screening for haematuria. The incidence of non-visible haematuria is similar in patients taking aspirin/warfarin to the general population hence these patients should also be investigated.

Testing
  • urine dipstick is the test of choice for detecting haematuria
  • persistent non-visible haematuria is often defined as blood being present in 2 out of 3 samples tested 2-3 weeks apart
  • renal function, albumin:creatinine (ACR) or protein:creatinine ratio (PCR) and blood pressure should also be checked
  • urine microscopy may be used but time to analysis significantly affects the number of red blood cells detected

NICE urgent cancer referral guidelines were updated in 2015.

Urgent referral (i.e. within 2 weeks)

Aged >= 45 years AND:
  • unexplained visible haematuria without urinary tract infection, or
  • visible haematuria that persists or recurs after successful treatment of urinary tract infection

Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test

Non-urgent referral

Aged 60 >= 60 years with recurrent or persistent unexplained urinary tract infection

Since the investigation (or not) of non-visible haematuria is such as a common dilemma a number of guidelines have been published. They generally agree with NICE guidance, of note:
  • patients under the age of 40 years with normal renal function, no proteinuria and who are normotensive do not need to be referred and may be managed in primary care
+PassMedicine Notes

The management of patients with haematuria is often difficult due to the absence of widely followed guidelines. It is sometimes unclear whether patients are best managed in primary care, by urologists or by nephrologists.

The terminology surrounding haematuria is changing. Microscopic or dipstick positive haematuria is increasingly termed non-visible haematuria whilst macroscopic haematuria is termed visible haematuria. Non-visible haematuria is found in around 2.5% of the population.

Causes of transient or spurious non-visible haematuria
  • urinary tract infection
  • menstruation
  • vigorous exercise (this normally settles after around 3 days)
  • sexual intercourse
Causes of persistent non-visible haematuria
  • cancer (bladder, renal, prostate)
  • stones
  • benign prostatic hyperplasia
  • prostatitis
  • urethritis e.g. Chlamydia
  • renal causes: IgA nephropathy, thin basement membrane disease
  • thin basement membrane disease
    • hereditary nephropathy characterised by diffuse thinning of the glomerular basement membrane (GBM), leading to persistent microscopic haematuria
    • autosomal dominant with variable penetrance
    • estimated to affect 1–5% of the general population worldwide
    • excellent prognosis
Spurious causes - red/orange urine, where blood is not present on dipstick
  • foods: beetroot, rhubarb
  • drugs: rifampicin, doxorubicin

Management

Current evidence does not support screening for haematuria. The incidence of non-visible haematuria is similar in patients taking aspirin/warfarin to the general population hence these patients should also be investigated.

Testing
  • urine dipstick is the test of choice for detecting haematuria
  • persistent non-visible haematuria is often defined as blood being present in 2 out of 3 samples tested 2-3 weeks apart
  • renal function, albumin:creatinine (ACR) or protein:creatinine ratio (PCR) and blood pressure should also be checked
  • urine microscopy may be used but time to analysis significantly affects the number of red blood cells detected

NICE urgent cancer referral guidelines were updated in 2015.

Urgent referral (i.e. within 2 weeks)

Aged >= 45 years AND:
  • unexplained visible haematuria without urinary tract infection, or
  • visible haematuria that persists or recurs after successful treatment of urinary tract infection

Aged >= 60 years AND have unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test

Non-urgent referral

Aged 60 >= 60 years with recurrent or persistent unexplained urinary tract infection

Since the investigation (or not) of non-visible haematuria is such as a common dilemma a number of guidelines have been published. They generally agree with NICE guidance, of note:
  • patients under the age of 40 years with normal renal function, no proteinuria and who are normotensive do not need to be referred and may be managed in primary care


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