Visible haematuria

Visible haematuria

Also known as 'macroscopic haematuria', 'gross haematuria' or 'frank haematuria', visible haematuria has a high diagnostic yield for urological malignancy since patients with visible haematuria represent a higher-risk group for urological malignancy than those presenting with non-visible haematuria. (1)

Visible haematuria is a presenting sign in more than 66% of patients with urological cancer (2)

• urine is coloured pink or red (or, on occasion like cola in acute glomerulonephritis).
• other rare causes of urine discolouration should be considered e.g. - (myoglobinuria, haemoglobinuria, beetroot ingestion, drug discoloration-rifampicin, doxorubicin) (3)

Macroscopic haematuria is associated with a higher prevalence of serious underlying pathology

• a prevalence of 22% for urological malignancies has been reported in patients with macroscopic haematuria

Key points (4):

• refer patients aged over 45 who present with unexplained visible haematuria (or persistent visible haematuria following successful treatment of a urinary tract infection) via an urgent cancer referral pathway
• patients with visible haematuria who are treated for urinary tract infection should have a repeat urine dipstick after completing their antibiotic course. If haematuria persists, refer them for further assessment
• offer transvaginal ultrasound imaging to women aged 55 and over who present with visible haematuria and either low haemoglobin levels, thrombocytosis, or high blood glucose levels, to assess for endometrial cancer

Notes (4):

• UTI may present with haematuria along with clinical features of UTI, specifically dysuria, new nocturia, and cloudy urine
  • other symptoms can include frequency and urgency
  • ask about a history of urethral discharge or sexually transmitted infections
• a patient with a long term catheter may experience visible haematuria, caused by recurrent UTI or traumatic catheterisation
  • a less common cause of visible haematuria in this group is malignancy, secondary to chronic irritation
    
    
• strenuous exercise, such as long distance running or non-weight bearing exercises such as swimming, can cause transient haematuria which is usually non-visible and resolves within 24-48 hours
  • repeat urine testing at least three days following exercise to confirm this
  • recurrent exercise induced haematuria should be investigated for an underlying cause
    
    
• haematuria mimics, including drugs such as rifampicin or chloroquine, or foodstuffs such as beetroot, blackberries, or red food dye, can cause red coloured urine in the absence of blood, which can be mistaken for visible haematuria
  • can be excluded using urine dipstick - if excluded in these instances, further investigation is not required
    
    
• in women, menstrual or vaginal bleeding can be excluded by taking a detailed menstrual history and undertaking a vaginal examination
  
  
• anticoagulation therapy can contribute to the manifestation of visible haematuria
  • up to 30% of patients will have a significant underlying pathology
    
    
• it is suggested to consider other benign pathologies when visible haematuria is associated with renal colic, flank pain, or lower urinary tract symptoms (LUTS)
  • the positive predictive value for urological malignancy in patients over 60 with visible haematuria was 3.9%, rising to 6.4% with associated dysuria
  • LUTS may be associated with benign prostatic hyperplasia
  • presence of proteins in a urine dipstick may be indicative of renal disease
    
    
• recurrent haematuria is indicative of underlying pathology, for example, calculi, UTI, and urothelial cancer
  • if the patient has previously presented with visible haematuria, check for any previous investigations or referrals

References:

1. Nielsen M, Qaseem A. Haematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016 Apr 5;164(7):488-97.
2. Edwards TJ et al. A prospective analysis of the diagnostic yield resulting from 4020 patients at a protocol-driven haematuria clinic. BJU Int. 2006 Feb;97(2):301-5.
3. Delanghe J et al. Pitfalls in the diagnosis of haematuria. Clinical Chemistry and Laboratory Medicine (CCLM). Volume 61 Issue 8. April 2023.
4. Madaan A, Gandhi N, Madaan S. Visible haematuria BMJ 2022; 376 :e067395 doi:10.1136/bmj-2021-067395