Is hematuria (presence of blood in urine) with blood clots normal during a Urinary Tract Infection (UTI)?

Blood Clots in Urine During UTI

Blood clots in urine (hematuria with clots) during a UTI is not normal and requires urgent urologic evaluation, as it may indicate a more serious underlying condition beyond a simple UTI.

Understanding Hematuria in UTIs

Hematuria can occur during UTIs but has important distinctions:

• Microscopic hematuria: Small amounts of blood detectable only on urinalysis may be seen with UTIs
• Gross hematuria: Visible blood in urine that may occur with UTIs, but is concerning
• Blood clots: Not typical of uncomplicated UTIs and suggest a more serious condition 1

While pyuria (white blood cells in urine) is considered a hallmark of true UTI 2, the presence of blood clots is not a typical feature of uncomplicated UTIs and warrants further investigation.

When to Seek Urgent Care

Urgent medical attention is needed if you have:

• Blood clots in urine (regardless of UTI symptoms)
• Bright red blood in urine
• Flank pain with hematuria
• Fever with gross hematuria

According to the American College of Physicians, all patients with gross hematuria require urgent urologic referral due to a >10% risk of urologic cancer 1.

Potential Causes When Blood Clots Appear During UTI

Blood clots during what seems to be a UTI may indicate:

1. Complicated UTI: Infection involving the upper urinary tract (pyelonephritis) or structural abnormalities
2. Urinary stones: Can cause both hematuria and UTI symptoms
3. Urologic malignancy: Research shows 20% of patients with UTI and hematuria were found to have urologic malignancy 3
4. Structural abnormalities: Such as lesions in the urinary tract

Diagnostic Approach

If you have blood clots with UTI symptoms:

1. Urinalysis and urine culture: To confirm infection and assess for pyuria 2
2. Imaging: Typically CT urography for adults with gross hematuria 1
3. Urologic referral: Mandatory for all cases of gross hematuria 1

Important Considerations

• Do not assume blood clots are simply due to the UTI
• The European Association of Urology notes that complicated UTIs may present with more severe symptoms and require more thorough evaluation 2
• Even with a positive urine culture, urologic evaluation should not be delayed in patients with hematuria and blood clots 3
• The presence of a UTI does not decrease the likelihood of having a urologic malignancy 3

Follow-up

After treatment of the UTI:

• If hematuria persists after treatment, further urologic evaluation is essential
• Repeat urinalysis should be performed after antibiotic treatment to ensure resolution
• New symptoms, persistent gross hematuria, or increased microscopic hematuria should prompt immediate re-evaluation 1

Remember that while UTIs commonly cause some degree of hematuria, blood clots are not typical and should never be dismissed as a normal finding of a UTI.