Investigation of haematuria

Preliminary investigations may be undertaken in primary care once transient causes of haematuria are excluded. These include:

• urinalysis: (1)
  • dipstick testing
    • to exclude other causes of a red urine
    • dipstick urinalysis for blood is indicated as part of the initial assessment of patients with
      • newly detected GFR < 60 ml/min/1.73 m2
      • newly discovered proteinuria
      • suspected multisystem disease with possible renal involvement
  • mid stream urine for (2):
    • microscopy
      • the presence of red cells excludes haemoglobinuria
      • presence of more than two red cells per high-power field on microscopy is abnormal (although the cut off point varies between ≥2 cells per high power field and≥5 cells per high power field) and requires further investigation
      • other findings may suggest infection or renal disease
    • culture and sensitivity - guides antibiotic selection if due to infection
  • 24-hour urine creatine clearance and urinary protein excretion - this is used to detect mild degrees of renal impairment
• blood tests:
• urea and electrolytes - to assess renal impairment
• full blood count - may require transfusion
• clotting - especially if taking anticoagulants
• imaging investigations include: (1)
  • plain film of kidney, ureters and bladder
  • intravenous urography
  • ultrasound scan - instead of, or in addition to, IVU

Further investigations may include (3):

• cystoscopy
• imaging
  • intravenous urography (IVU)/intravenous pyelography (IVP)
  • USS
  • CT scan
  • MRI
• renal biopsy - if histological diagnosis is indicated

Note:

• there is no need in routine clinical practice for confirmation of haematuria by microscopy of a midstream urine sample (2)

References:

1. Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU Guideline. J Urol. 2020 Oct;204(4):778-86.
2. Bolenz C, Schroppel B, Eisenhardt A, et al. The Investigation of Hematuria. Dtsch Arztebl Int. 2018 Nov 30;115(48):801-807
3. Blick CG, Nazir SA, Mallett S, et al. Evaluation of diagnostic strategies for bladder cancer using computed tomography (CT) urography, flexible cystoscopy and voided urine cytology: results for 778 patients from a hospital haematuria clinic. BJU Int. 2012 Jul;110(1):84-94.