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Saturday, August 23, 2025

Blood in urine


Blood in Urine (Hematuria)

Introduction

Hematuria is the presence of red blood cells in urine. It is a common but potentially serious symptom. While benign causes exist (exercise, mild infections), hematuria may also signal life-threatening disease (cancer, kidney disease, severe infection).

It is classified as:

  • Gross hematuria: Blood visible in urine (red, pink, cola-colored).

  • Microscopic hematuria: Detected only under microscope or dipstick test.

Pathophysiology

  • Blood enters urine from anywhere along the urinary tract: kidneys, ureters, bladder, prostate, or urethra.

  • The cause may be inflammatory, infectious, traumatic, malignant, or systemic.

  • Differentiation between glomerular (kidney origin) and non-glomerular hematuria is crucial:

    • Glomerular: Brown, cola-colored urine, often with proteinuria or casts.

    • Non-glomerular: Bright red urine, clots, usually lower tract source.

Causes of Hematuria

1. Urinary Tract Infections (UTIs)

  • Cystitis (bladder infection).

  • Pyelonephritis (kidney infection).

  • Prostatitis (in men).

2. Urolithiasis (Stones)

  • Kidney or bladder stones → sharp pain, hematuria, possible infection.

3. Malignancy

  • Bladder cancer (painless gross hematuria is a red flag).

  • Kidney cancer (renal cell carcinoma).

  • Prostate cancer.

4. Kidney Disease

  • Glomerulonephritis (IgA nephropathy, lupus nephritis).

  • Polycystic kidney disease.

  • Post-streptococcal GN.

5. Trauma

  • Injury to kidney, bladder, urethra.

  • Post-catheterization or recent surgery.

6. Medications

  • Anticoagulants (warfarin, heparin, DOACs).

  • Cyclophosphamide (hemorrhagic cystitis).

  • NSAIDs (renal papillary necrosis).

7. Other Causes

  • Benign prostatic hyperplasia (BPH).

  • Strenuous exercise (“runner’s hematuria”).

  • Sickle cell disease.

  • Endometriosis involving urinary tract (rare).

Clinical Features

  • Urine color: Pink, red, cola, or brown.

  • Associated symptoms:

    • Dysuria, frequency, urgency → UTI.

    • Flank pain, renal colic → stones.

    • Painless hematuria → bladder/kidney cancer.

    • Fever, malaise → infection or systemic disease.

    • Lower urinary tract symptoms (weak stream, hesitancy) → BPH, prostate cancer.

  • Systemic symptoms:

    • Weight loss, night sweats (cancer).

    • Joint pain, rash (autoimmune GN).

    • Hematuria + proteinuria + hypertension (renal disease).

Diagnostic Approach

1. History

  • Visible or microscopic hematuria?

  • Painful or painless?

  • Associated symptoms (fever, dysuria, colic, weight loss).

  • Medication history (anticoagulants, cyclophosphamide).

  • Smoking history (risk for bladder cancer).

  • Family history of renal disease or cancer.

2. Examination

  • Vitals: fever, hypertension.

  • Abdominal exam: flank tenderness, masses.

  • Rectal exam (men): prostate enlargement or nodules.

  • Pelvic exam (women): rule out gynecological source.

3. Investigations

  • Urinalysis: RBCs, WBCs, nitrites, protein, casts.

  • Urine culture: If infection suspected.

  • Urine cytology: Cancer detection.

  • Blood tests: CBC, renal function, electrolytes, clotting profile.

  • Imaging:

    • Ultrasound kidney/bladder.

    • CT urogram (best for stones, tumors).

    • MRI if contrast contraindicated.

  • Cystoscopy: Direct bladder visualization (gold standard for bladder cancer).

  • Kidney biopsy: If glomerulonephritis suspected.

Management and Treatment

Treatment targets the underlying cause.

A. Urinary Tract Infections

  • Nitrofurantoin 100 mg orally twice daily × 5–7 days.

  • Trimethoprim–sulfamethoxazole 160/800 mg orally twice daily × 3–5 days.

  • Ciprofloxacin 500 mg orally twice daily × 7 days (reserved for resistant cases).

B. Kidney and Bladder Stones

  • Hydration, pain control:

    • Ibuprofen 400 mg orally every 8 h.

    • Morphine 2–5 mg IV for severe colic.

  • Medical expulsion therapy:

    • Tamsulosin 0.4 mg orally once daily.

  • Larger stones → lithotripsy or surgical removal.

C. Malignancies

  • Bladder cancer: Transurethral resection, intravesical BCG, chemotherapy.

  • Renal cell carcinoma: Nephrectomy, targeted therapy (sunitinib, pazopanib).

  • Prostate cancer: Surgery, radiotherapy, androgen deprivation therapy.

D. Glomerular Diseases

  • IgA nephropathy, lupus nephritis, post-strep GN:

    • Immunosuppressives: Prednisone 0.5–1 mg/kg/day.

    • Cytotoxic drugs if severe: Cyclophosphamide 1–2 mg/kg/day orally.

    • ACE inhibitors (Enalapril 5–20 mg daily) for proteinuria and hypertension.

E. Trauma

  • Supportive, catheterization, surgical repair if severe.

F. Medication-Induced Hematuria

  • Review anticoagulant dose.

  • Stop offending drugs (e.g., cyclophosphamide → consider Mesna to protect bladder).

G. Benign Prostatic Hyperplasia (BPH)

  • Tamsulosin 0.4 mg orally daily.

  • Finasteride 5 mg orally daily.

  • TURP (transurethral resection of prostate) if severe.

Complications

  • Anemia from chronic blood loss.

  • Recurrent infections.

  • Renal obstruction and failure (stones, tumors).

  • Missed malignancy → delayed cancer diagnosis.

Prognosis

  • Infections and stones: Excellent with treatment.

  • Glomerular disease: Variable; early treatment prevents progression.

  • Bladder/kidney/prostate cancer: Prognosis depends on stage at diagnosis.

  • Unexplained hematuria: Requires ongoing monitoring.

Patient Education

  • Blood in urine should never be ignored.

  • Even if painless, it may signal cancer.

  • Maintain hydration, avoid smoking, limit NSAIDs.

  • Complete antibiotics if prescribed.

  • Report recurrence, blood clots, or systemic symptoms immediately.

  • Regular screening and follow-up if risk factors present.





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