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ULY CLINIC
ULY CLINIC
11 Septemba 2025, 06:15:58
Hematuria (Blood in Urine)
Hematuria, the abnormal presence of red blood cells (RBCs) in urine, is a cardinal sign of renal and urinary tract disorders. By definition, hematuria is confirmed when three or more RBCs are detected per high-power microscopic field in urine.
Microscopic hematuria: Blood is detectable only under a microscope or via chemical testing (occult blood test).
Macroscopic (gross) hematuria: Blood is visibly present in urine. Must be distinguished from pseudohematuria, which can occur from foods, medications, or contamination.
Macroscopic hematuria may be continuous or intermittent, often associated with pain, and sometimes aggravated by prolonged standing or physical activity.
Classification by stage of urination
Initial hematuria: Bleeding at the start of urination; usually urethral in origin.
Terminal hematuria: Bleeding at the end of urination; usually originates from bladder neck, posterior urethra, or prostate.
Total hematuria: Bleeding throughout urination; usually indicates upper urinary tract or renal pathology.
Mechanism
Vessel rupture/perforation: Trauma or vascular injury in renal or urinary tract.
Glomerular filtration defect: RBCs pass through damaged glomeruli.
Color clues:
Dark or brownish urine → renal or upper urinary tract bleeding
Bright red urine → lower urinary tract bleeding
Hematuria may also result from GI, prostate, vaginal, coagulation disorders, certain drugs, or invasive procedures. Non-pathologic causes include fever, hypercatabolic states, or strenuous exercise.
History and physical examination
History
Onset, duration, and pattern of hematuria (initial, terminal, total)
Associated pain, burning, or passage of clots
Past history of renal, urinary, or coagulation disorders
Medication history (anticoagulants, aspirin)
Recent trauma, strenuous exercise, or urologic procedures
Rule out menstrual contamination or hemorrhoidal bleeding
Physical examination
Abdominal and flank palpation/percussion
Costovertebral angle (CVA) tenderness
Urinary meatus inspection
Urine dipstick for protein
Vaginal or digital rectal exam if indicated
Common medical causes
Cause | Clinical Features | Distinguishing Points |
Bladder cancer | Gross hematuria, bladder/rectal/pelvic/flank/back pain, dysuria, urinary frequency/urgency, nocturia | More common in men; may include vomiting, diarrhea, insomnia |
Bladder trauma | Hematuria with lower abdominal pain, occasional anuria, swelling of scrotum/perineum | History of trauma; may show shock signs |
Calculi (renal/bladder) | Hematuria ± colicky flank pain, dysuria, urinary frequency | Renal stones: severe flank-to-genital pain; bladder stones: referred lower back or genital pain |
Coagulation disorders | Gross hematuria, epistaxis, purpura, GI bleeding | Lab evidence of thrombocytopenia, DIC, or hemophilia |
Cortical necrosis (acute) | Gross hematuria, intense flank pain, fever, anuria | Rare, usually post-shock or sepsis |
Cystitis (bacterial/interstitial/viral/tubercular) | Urinary urgency, frequency, dysuria, nocturia, suprapubic/perineal pain | Bacterial: acute; Interstitial: chronic; Tubercular: persistent, low-grade fever |
Diverticulitis (bladder involvement) | Microscopic hematuria, LLQ pain, constipation/diarrhea, abdominal mass | Often associated with low-grade fever, mild nausea |
Glomerulonephritis | Gross → microscopic hematuria, red cell casts, proteinuria, edema, HTN, fatigue | Acute: oliguria/anuria; Chronic: persistent microscopic hematuria |
Nephritis (interstitial) | Microscopic hematuria, fever, rash, oliguria/anuria | Chronic: dilute urine, polyuria, hypertension |
Obstructive nephropathy | Micro/macro hematuria, colicky flank pain, oliguria/polyuria | Usually due to obstruction; urine rarely grossly bloody |
Polycystic kidney disease | Recurrent hematuria, flank pain, polyuria, hypertension | Swollen abdomen, proteinuria; hereditary disorder |
Prostatitis (acute/chronic) | Terminal hematuria, dysuria, urinary urgency/frequency | Acute: fever, malaise, perineal/back pain; chronic: persistent urethral discharge, ejaculatory pain |
Pyelonephritis (acute) | Micro/macro hematuria progressing to gross, flank pain, CVA tenderness, fever, nausea, vomiting | May persist microscopically post-infection |
Renal cancer | Gross hematuria, flank/side pain, abdominal mass, colicky pain | May include fever, CVA tenderness, HTN, weight loss |
Renal infarction | Gross hematuria, severe flank/upper abdominal pain, CVA tenderness, anorexia | May develop fever and hypertension after 1–2 days |
Renal papillary necrosis | Gross hematuria, flank pain, CVA tenderness, colicky pain | Often post-analgesic abuse, sickle cell disease, diabetes |
Renal trauma | Micro/macro hematuria, flank mass, ecchymosis, oliguria | History of trauma; shock signs possible |
Renal tuberculosis | Gross hematuria, dysuria, urinary frequency, colicky pain | May present with palpable lower abdominal mass |
Renal vein thrombosis | Gross hematuria, flank/lumbar pain, fever, pallor, edema | Abrupt: severe pain, oliguria/anuria; Gradual: nephrotic syndrome signs |
Schistosomiasis | Terminal hematuria, dysuria, colicky pain, palpable bladder mass | Endemic areas; parasitic infection |
Sickle cell anemia | Gross hematuria, pallor, polyarthralgia, fatigue, hepatomegaly | RBC sickling causes renal papillary congestion |
Systemic lupus erythematosus (SLE) | Gross hematuria, proteinuria, joint pain, butterfly rash, photosensitivity | Multisystem involvement; may show psychosis or recurrent fever |
Urethral trauma | Initial hematuria, blood at meatus, local pain, ecchymoses | History of trauma |
Vasculitis | Usually microscopic hematuria, malaise, myalgia, fever, pallor | May show urticaria, purpura depending on etiology |
Other causes
Diagnostic procedures: Renal biopsy, cystoscopy, instrumentation
Drugs: Anticoagulants, aspirin, analgesics, cyclophosphamide, phenylbutazone, rifampin, herbal remedies (garlic, Ginkgo biloba)
Management and special considerations
Provide emotional support; hematuria can be alarming
Monitor vital signs at least every 4 hours
Record intake and output, noting pattern and amount of hematuria
Ensure urinary catheter patency; irrigate to prevent clot obstruction
Administer analgesics and enforce bed rest as needed
Prepare for diagnostic tests: urine studies, cystoscopy, renal imaging, biopsy
Patient counseling
Instruct on three-glass urine collection technique for accurate serial testing
Encourage adequate fluid intake
Discuss medication and herbal supplement interactions
Pediatric considerations
Common causes: congenital anomalies (obstructive uropathy, renal dysplasia), birth trauma, hematologic disorders (vitamin K deficiency, hemolytic-uremic syndrome, hemophilia), Wilms tumor, bladder cancer, rhabdomyosarcoma
Artifactual hematuria: recent circumcision
Drugs like cyclophosphamide have higher hematuria risk
Geriatric considerations
Evaluate with urine culture, excretory urography/sonography, and urologist consultation
Age-related comorbidities may influence management
References
Berthoux, F., Suzuki, H., Thibaudin, L., et al. (2012). Autoantibodies targeting galactose-deficient IgA1 associate with progression of IgA nephropathy. Journal of the American Society of Nephrology, 23, 1579–1587.
Roberts, I. S., Cook, H. T., Troyanov, S., et al. (2009). The Oxford classification of IgA nephropathy: Pathology definitions, correlations, and reproducibility. Kidney International, 76, 546–556.
McPherson, R. A., & Pincus, M. R. (2017). Henry’s Clinical Diagnosis and Management by Laboratory Methods (23rd ed.). Philadelphia: Elsevier.
Campbell-Walsh Urology (12th Edition). Elsevier, 2020.