From the Guidelines
Haematuria in New Zealand requires prompt medical evaluation, and patients with gross haematuria should undergo a full urologic workup due to the high association with malignancy of up to 30% to 40%. The management pathway typically involves initial assessment by a GP who will perform a dipstick urinalysis test to confirm haematuria, followed by urine microscopy, culture and sensitivity testing to rule out infection 1. Further investigations include blood tests to assess kidney function and imaging such as ultrasound or CT urogram.
Key Considerations
- Patients over 40 with unexplained haematuria are often referred to a urologist for cystoscopy to examine the bladder lining.
- Common causes in New Zealand include urinary tract infections (treated with antibiotics like trimethoprim 300mg daily for 3 days or nitrofurantoin 100mg twice daily for 5 days), kidney stones (managed with pain relief such as paracetamol or NSAIDs and increased fluid intake), and bladder or kidney cancers.
- New Zealand has specific referral guidelines where visible haematuria requires urgent specialist referral within two weeks, while non-visible haematuria may warrant routine referral.
Population Considerations
- The prevalence of haematuria-causing conditions varies among different population groups in New Zealand, with Māori and Pacific peoples having higher rates of certain urological cancers, making cultural sensitivity in assessment important.
- Patients with suspected urinary tract infection as a cause of microhematuria should have urine cultures performed, preferably before antibiotic therapy, to confirm an infection 1.
- Patients with a suspected cause of microhematuria, including interstitial cystitis or benign prostatic hyperplasia, should have the appropriate clinical workup before undertaking imaging, including a pelvic examination in women, a rectal examination in men, and cystoscopy 1.
From the Research
Prevalence and Causes of Haematuria
- Haematuria has a prevalence of 0.1% to 2.6% 2
- Potential diagnoses may include infection, kidney stones, trauma, exercise or spurious causes, such as foods, drugs or menstruation, and a tumour 2
- Approximately 20% of patients with haematuria have a urological tumour, with a further 20% found to have a significant underlying pathology 2
Investigation and Management of Haematuria
- A patient with visible haematuria requires urgent, stringent investigation, warranting specialist assessment and subsequent selective referral through a series of patient-centred investigations at a haematuria clinic 2
- Careful clinical assessment and basic laboratory tests for renal function, analysis of the urinary sediment and cytological examination of the urine are followed by ultrasound and plain radiography of the urinary tract 3
- Flexible cystoscopy under local anaesthetic is central to the algorithm in patients of all ages 3
- The importance of a nephrological opinion and consideration of renal biopsy, especially in younger patients with other evidence of glomerular disease, is stressed 3
Diagnosis and Treatment of Underlying Conditions
- Haematuria is subsequently known as the 'classic presentation' of bladder cancer with 70-80% of patients experiencing painless, gross (visible) haematuria 2
- Between 20% and 25% of people with visible blood in their urine and 5-10% of people with non-visible blood in their urine will be diagnosed with a urological malignancy, i.e. bladder, kidney or prostate cancer 4
- The sensitivity of ultrasound with respect to bladder cancer was 63% and the specificity 99% 5
- An ultrasonography-based protocol could miss fewer upper tract TCCs than a standard IVU-based service would miss renal cell cancer 5
Management Pathway for Macroscopic Haematuria
- A management pathway that can be used in the emergency department includes baseline investigation, treatment, and follow-up 6
- Baseline investigation in the ED includes full blood count, urea and electrolyte levels, midstream urine dipstick, beta human chorionic gonadotrophin, and formal microscopy, culture and sensitivities 6
- Treatment of macroscopic haematuria aims at RESP--Resuscitation, Ensuring, Safe and Prompt 6
- Indications for admission include clot retention, cardiovascular instability, uncontrolled pain, sepsis, acute renal failure, coagulopathy, severe comorbidity, heavy haematuria or social restrictions 6