What is the appropriate management and treatment for haematuria (blood in urine)?

Management and Treatment of Haematuria

The management of haematuria requires immediate risk stratification based on whether it is gross (macroscopic) or microscopic, followed by targeted evaluation with urologic referral for all gross haematuria and risk-stratified imaging and cystoscopy for microscopic haematuria based on age, smoking history, and degree of haematuria. 1

Initial Confirmation and Exclusion of Benign Causes

Before initiating extensive workup, confirm true haematuria with microscopic examination showing ≥3 red blood cells per high-power field, rather than relying solely on dipstick results 2. This is critical because dipstick can produce false positives.

Exclude transient benign causes first:

• Menstruation: Repeat urinalysis 48 hours after cessation; if resolved, no further workup needed 3
• Vigorous exercise: Repeat urinalysis 48 hours after cessation 2
• Urinary tract infection: Obtain urine culture before antibiotics, treat appropriately, and repeat urinalysis 6 weeks post-treatment to confirm resolution 2
• Viral illness: Rule out as potential cause 2

Critical pitfall: Never attribute haematuria solely to anticoagulation or antiplatelet therapy without complete evaluation, as these medications unmask underlying pathology rather than cause haematuria 1, 2

Risk Stratification for Malignancy

Gross (macroscopic) haematuria carries 30-40% malignancy risk and mandates immediate urologic referral, even if self-limited 1, 2. This is non-negotiable regardless of patient age or other factors.

For microscopic haematuria, stratify by the following risk factors 1:

Age-based risk:

• Women <60 years: Low risk
• Women ≥60 years: Intermediate risk
• Men <40 years: Low risk
• Men 40-59 years: Intermediate risk
• Men ≥60 years: High risk

Smoking history:

• Never smoker or <10 pack-years: Low risk
• 10-30 pack-years: Intermediate risk

• 30 pack-years: High risk

Degree of haematuria:

• 3-10 RBC/HPF: Low risk

• 10 RBC/HPF: Higher risk

Additional high-risk features 2:

• Occupational exposure to chemicals/dyes (benzenes, aromatic amines)
• History of pelvic irradiation
• Irritative voiding symptoms
• Analgesic abuse

Determining Glomerular vs. Non-Glomerular Source

This distinction fundamentally changes management pathways 2.

Glomerular source indicators:

• Dysmorphic RBCs >80% on urinary sediment examination 2
• Red cell casts 2
• Significant proteinuria (>500 mg/24 hours) 2
• Tea-colored urine 1
• Elevated serum creatinine 2

If glomerular source suspected:

• Measure serum creatinine and assess for proteinuria 2
• Consider 24-hour urine collection to quantify protein excretion if dipstick shows persistent proteinuria 3
• Refer to nephrology if: proteinuria >500 mg/24 hours (especially if increasing), proteinuria >1,000 mg/24 hours, red cell casts present, or predominantly dysmorphic RBCs 3
• Ultrasound is appropriate to assess kidney size and anatomy before potential renal biopsy 4

Imaging Strategy for Non-Glomerular Haematuria

For adults with microscopic haematuria and risk factors (non-glomerular source):

CT urography is the most sensitive and specific imaging modality for detecting urologic malignancy, particularly urothelial tumors 4, 5. The protocol includes:

• Unenhanced phase (for calculi detection)
• Nephrographic phase (for renal masses and parenchymal disease)
• Excretory phase (for urothelial abnormalities) 6

Alternative imaging considerations:

• Ultrasound: First-line for radiation-sensitive patients, low-risk patients, young men <40 years, pregnant patients, and those with renal impairment 5
• MR urography: Better contrast resolution without radiation or IV contrast, suitable for pediatric patients, pregnant patients, and those with renal impairment 5

For children with isolated microscopic haematuria without proteinuria: No imaging is indicated initially, as patients without proteinuria or dysmorphic RBCs are unlikely to have clinically significant renal disease 4. CT is not appropriate in pediatric evaluation of isolated nonpainful, nontraumatic haematuria 4.

Cystoscopy Requirements

Cystoscopy is mandatory for:

• All patients with gross haematuria 5
• Patients with non-glomerular microscopic haematuria and risk factors 2

Cystoscopy remains the gold standard for detecting lower urinary tract (bladder) urothelial tumors 5.

Follow-Up Protocol for Negative Initial Evaluation

If initial evaluation is negative but microscopic haematuria persists, repeat urinalysis at 6,12,24, and 36 months 2. During follow-up:

• Monitor blood pressure 2
• Reassess for development of proteinuria 2
• Consider nephrology referral if haematuria persists with development of hypertension, proteinuria, or evidence of glomerular bleeding 2

Special Populations

Pregnant patients: MR urography or ultrasound preferred to avoid radiation exposure 5

Patients on anticoagulation: Complete full evaluation as anticoagulation does not cause haematuria but may unmask underlying pathology 1

Pediatric patients with trauma:

• Macroscopic haematuria post-trauma: Imaging required to identify extent of renal or urinary tract injury 4
• Microscopic haematuria post-trauma: Clinical context determines imaging need 4

Common Pitfalls to Avoid

• Never ignore gross haematuria, even if self-limited—it requires urologic referral 1, 2
• Do not assume menstruation is the cause without proper verification through repeat testing after menstruation 3
• Do not forgo evaluation in patients on anticoagulation 1
• Do not perform extensive imaging in children with isolated microscopic haematuria without proteinuria or dysmorphic RBCs 4
• Always obtain urine culture before antibiotics if infection suspected 2