Hematuria in Males and Females: causes, types, diagnosis and treatment

What is Hematuria?

Hematuria is simply defined as blood in urine. There could be Microscopic or Gross Hematuria – where the blood in the urine is not seen with the eyes (it is referred to as microscopic hematuria) while the one seen and which makes the urine red is called gross hematuria. Because of these differences, it is better to define it using the laboratory findings the presence of more than 3 to 5 Red blood cells (RBC) per high power field of a microscope is termed hematuria.

Classification and types of Hematuria

1. Based on timing, there could be Initial, Total or Terminal hematuria
2. Based on pains painful or painless hematuria
3. Based on visibility there is microscopic and gross hematuria

Malignant cells seen on cytology while investigating the cause of hematuria

Initial hematuria

This type occurs at the beginning of micturition when you are urinating, the urine immediately starts with blood but while urinating, the urine begins to clear and does not end with blood. This occurs in urethritis or urethral stricture

Total Hematuria

This type of hematuria is the commonest and occurs when the urine starts with blood, continues and ends with blood this means it occurs throughout the period of micturition (urination). This occurs in stones, tumor, tuberculosis or nephritis.

Terminal Hematuria

Terminal hematuria occurs only at the end of urination that is, the urine becomes reddish at the end of micturition. This occurs in lesions of the posterior urethra, bladder neck or trigone.

Painful hematuria

This type of hematuria occurs when the process of urination is painful and occurs with blood in the urine. This type of hematuria may be a symptom of infection, stones in the urinary tract or trauma to the urinary tract.

Painless hematuria

This type of hematuria does not occur with pain and it is a common symptom of tumors of the urinary tract.

Microscopic hematuria

This occurs when the urine appears to be normal and can only be detected when viewed with an light microscope the presence of 3 to 5 red cells per high power field is termed hematuria.

Macroscopic or gross hematuria

This type makes the urine reddish and blood can be seen in the urine with blood clots occurring sometimes.

Massive Hematuria

Hematuria is described as massive when blood loss is of such a magnitude as to result in significant hemodynamic derangement. This is an acute emergency requiring the institution of promptresuscitative measures.

Laboratory findings while investigating the cause of Hematuria

Etiology of Hematuria (Causes of blood in urine)

1. Use of drugs such as Anticoagulants like warfarin and heparin
2. Blood abnormalities causing disorder of coagulation such as hemophilia
3. Blood cancer such as leukemia
4. Solid tumors such as lymphomas
5. Scurvy
6. Sickle cell anemia
7. Congenital cause such as polycystic kidney disease
8. Trauma to the urinary tract
9. Infections affecting the urinary tract
10. Stones impacted along the urinary tract
11. Blockage of blood supply leading to dead of tissues such as in renal artery embolism and renal vein thrombosis causing infarction (dead of tissue due to blockage of blood supply)
12. Renal cell carcinoma
13. Carcinoma of the renal pelvis
14. Foreign bodies in the urinary tract
15. Carcinoma of the prostate (occurs in men alone)
16. Benign prostate hyperplasia (also in men alone)

Causes of red urine that may mimic hematuria (differentials of hematuria)

1. Hemoglobinuria
2. Myoglobinuria
3. Taking of Rifampicin drug for treatment of Tuberculosis
4. Taking of Anthocyanin containing foods such as beet and blackberries
5. Use of Phenothiazines
6. Dindevan
7. Trianol
8. Sulphonal
9. Chronic lead or mercury poisoning

Signs and symptoms of Hematuria

Symptoms of hematuria could be asymptomatic (may not even show sign) and are detected on urinalysis. Care should be taken especially in diagnosis of hematuria in females as there may be contamination from menstrual flow which may seem as if the woman has hematuria but may not (false positive result).

Also not all red colored urine is termed hematuria as there are other causes of red urine which are listed below.

Please note that hematuria is not a disease but a sign of disease. Sign and symptoms used here is for understanding of non-medical personnel and shows the signs that points to the cause of the hematuria and not signs that diagnose hematuria.

Symptoms and signs that points to cause of Hematuria

1. Blood at the meatus likely urethral trauma
2. Urethral discharge likely urinary tract infection
3. Urethral induration likely urinary stricture
4. Associated lower urinary tract symptoms such as Frequency, Urgency, Hesitancy, and Feeling of residual urine urinary tract infection
5. There may be presence of abdominal mass or swelling suggesting tumor as a cause of the hematuria
6. Constitutional symptoms such as anorexia , weight loss and fever occurring in a patient with hematuria points to cancer
7. There may be features of renal impairment such as facial puffiness, leg swelling, hiccups, and persistent vomiting

Additional test for diagnosis of the cause of Hematuria

Investigation and Diagnosis of Hematuria

1. Dipstick Urinalysis: appearance may be positive for blood; and presence of Protein <100mg/dl is suggestive of surgical cause.
2. Urine Microscopy will show red blood cells cast; if red blood cells are found and appear normal, then the hematuria is a non-glomerular type or of a surgical cause. If the RBCs appear dysmorphic (altered shaped), then it is a glomerular type or it is said to be of medical cause
3. Urine cytology helps to detect malignant cells
4. Serum calcium, uric acid, cystine, and Phosphate may point to presence of stones
5. Traditional 4 Test approach to diagnosing the cause of hematuria includes urine cytology, cystoscopy, ultrasound scan (USS) and intravenous urography (IVU)

Many other investigations may be requested depending on the presentation of the patient.

Urethrocystoscopy for visualizing the urethra and bladder used in diagnosis of the cause of hematuria

Hematuria treatment

Hematuria management depends on the presentation. First, the patient is resuscitated by the following:

1. In a trauma setting , do ABC of resuscitation
2. Take urgent PCV
3. Group and cross match blood and carry out blood transfusion where necessary

The Definitive management of hematuria

For Renal pathologies: in cases of renal tumors a radical nephrectomy is done or radiotherapy; for stones the use of Extracorporeal shock wave lithotripsy (ECSW Lithotripsy) and for infections the appropriate antibiotics are used.

In the case of Schistosomiasis Praziquantel can be used for treatment.

In prostatic diseases such as benign prostate hyperplasia (BPH) treatment involves Transurethral resection of the prostate (TURP) or open prostatectomy; whereas for carcinoma of the prostate – radical prostatectomy is done for early tumors and bilateral total orchidectomy (or Orchiectomy) and hormone therapy using leuprolein can be done for advanced cancers.