Macroscopic Haematuria- visible blood in the urine

Microscopic Haematuria- not visible but identified by urine microscopy or dipstick test.  This may be symptomatic or asymptomatic.  Defined as >3 red blood cells in the urine.

NB Be wary that dipsticks actually detect haem, and can (in some uncommon situations) be false negative/positive.  Also recognise that it can be normal to have asymptomatic microscopic haematuria, which usually doesn’t require investigation.

  • In children and young people, glomerular causes are more predominant.  In older people, this decreases and cancer and stone disease become more common.

Assessment and Investigation

What is significant haematuria?

  • Any single episode of macroscopic haematuria
  • Any single episode of symptomatic microscopic haematuria in the absence of UTI and other transient causes
  • Persistent asymptomatic microscopic haematuria (2 out of 3 separate urinalysis) in the absence of UTI and other transient causes
    • NB the presence of haematuria should NOT be attributed to anti-coagulant/anti-platelet therapy, unless trauma (e.g. traumatic catheterisation) is present.


  • A renal cause such as glomerulonephritis will generally cause persistent microscopic haematuria with or without periods of gross haematuria
  • Gross haematuria associated with renal causes will usually be present throughout the stream
    • if haematuria is only present at the start of stream- it is suggestive of a distal urethral cause e.g. urethritis
    • if only present at the end- it is suggestive of upper urethral/prostatic/trigonal cause
      • this said, bladder cancer and other bladder causes can often present as gross haematuria throughout the stream

Associated symptoms

  • Pain- usually associated with stone disease or infection
  • Rash, arthralgia, fatigue- may be associated with an inflammatory/immune mediated cause
  • Fatigue, night sweats and weight loss may be present with neoplastic causes


  • EXCLUDE UTI- Urine dipstick should always be done first
    • Nitrites and leucocyte markers suggest UTI
    • Protein suggests nephrological cause e.g. glomerulonephritis
    • MSSU should follow any abnormal dipstick to further evaluate findings
  • Symptomatic microscopic haematuria and asymptomatic persistent microscopic haematuria should be further investigated:
    • Blood pressure
    • Creatinine/eGFR (renal function)
    • Urine sample for protein/creatinine ratio (normally <50) or albumin/creatinine ratio (normally (<30)
  • All macroscopic haematuria should be investigated by urology with some form of imaging
    • Usually Cystoscopy + USS or CT KUB
  • All patients with symptomatic haematuria (inc macroscopic haematuria) and all patients >40 years old with any significant haematuria should be referred to urology.  Referal to renal medicine should be made if eGFR/creatinine or PCR/ACR are abnormal and/or a renal cause is suspected.

Potential Causes

  • Cancer:
    • Bladder (TCC, Squamous cell carcinoma); Kidney (Renal cell adenocarcinoma); Renal pelvis/ureter (TCC); prostate
  • Stones (kidney/ureteric/bladder)
  • Infection
    • bacterial, mycobacterial (TB), parasitic (schistosomiasis), infective urethritis
  • Inflammation
    • Cyclophosphamide cystitis, interstitial cystitis
  • Trauma
    • In particular catheterisation and pelvic fractures
  • Renal Cystic disease
  • Nephrological causes (consider particularly in children/young adults; or with accompanying significant proteinuria; blood often takes form of red cell casts)-
    • IgA Nephropathy, post-infective glomerulonephritis, membrano-proliferative glomerulonephritis, Henoch-Schonlein purpura, vasculitis, Alport’s syndrome, thin basement membrane disease, Fabry’s disease etc
  • Other causes
    • Anticoagulation therapy; sickle cell/hemophilia; renal papillary necrosis



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