Haematuria

Terminology

Visible haematuria—replaces macroscopic and gross haematuria
Non-visible haematuria—replaces microscopic and dipstick positive haematuria
Symptomatic non-visible haematuria—non-visible haematuria plus lower urinary tract symptoms (hesitancy, frequency, urgency, dysuria) or upper urinary tract symptoms
Asymptomatic non-visible haematuria—incidental detection of non-visible haematuria in the absence of upper or lower urinary tract symptoms

Diagnosis of haematuria

Exclude transient causes, such as urinary tract infection, before further assessment
A urine dipstick test for blood is generally sufficient. It is sensitive when performed on fresh voided urine with no preservatives. A score of ≥1+ is positive; a trace amount is considered negative
A positive result for haemolysed red blood cells should be treated the same as for non-haemolysed red cells
Further assessment is warranted in patients with urinary tract symptoms and non-visible haematuria and a score of ≥1+ on a single blood dipstick test
In patients with asymptomatic non-visible haematuria confirm persistence of blood in at least two out of three dipstick tests
It is not necessary to confirm the dipstick result by microscopy

Urological causes
- Common
  - Benign prostatic hyperplasia
  - Cancer (bladder, kidney, prostate, ureter)
  - Calculus disease or nephrolithiasis
  - Cystitis or pyelonephritis
  - Prostatitis or urethritis
  - Schistosoma haematobium infection
- Less common
  - Radiation cystitis
  - Urethral strictures
  - Tuberculosis
  - Medullary sponge kidney
  - Cyclophosphamide induced cystitis
- Rare
  - Arteriovenous malformation
  - Renal artery thrombosis
  - Polycystic kidney disease
  - Papillary necrosis of any cause
  - Loin pain haematuria syndrome
Nephrological causes
- Common
  - IgA nephropathy (Berger’s disease)
  - Thin basement membrane disease
- Less common
  - Acute glomerular disease:
    - Postinfectious glomerulonephritis
    - Rapidly progressive glomerulonephritis
    - Systemic lupus nephritis
    - Vasculitis
    - Goodpasture’s disease
    - Henoch-Schönlein purpura syndrome
    - Haemolytic-uraemic syndrome
  - Chronic primary glomerulonephritis:
    - Focal segmental glomerulonephritis
    - Mesangio-capillary glomerulonephritis
    - Membranous nephropathy
    - Mesangial proliferative glomerulonephritis
  - Familial causes:
    - Polycystic kidney disease (autosomal dominant or recessive)
    - Hereditary nephritis (Alport’s syndrome)
    - Fabry’s disease
    - Nail-patella syndrome

MSU
Plasma creatinine and estimated glomerular filtration rate
Measure proteinuria—send a random sample of urinefor protein:creatinine ratio or albumin:creatinine ratio (accordingto local practice). Twenty four hour urine collections for proteinare rarely needed—24 hour urine protein or albumin excretion(in mg) can be approximated by multiplying the ratio (in mg/mmol)by 10
Measure blood pressure

All patients with visible or non-visible haematuria who have urinary tract symptoms should be referred for urological assessment
Patients aged ≥40 with asymptomatic non-visible haematuria should be referred for urological assessment
Patients under 40 with asymptomatic non-visible haematuria need urological assessment only if the estimated glomerular filtration rate is reduced (<60 ml/min) or proteinuria is >0.5 g/d
Patients with no abnormal findings on urological assessment need long term observation, usually in primary care. Patients should be reassessed if they develop visible haematuria or urinary tract symptoms. Nephrology assessment is recommended for falling renal function or new or increasing proteinuria