Haematuria in Specific Clinical Situations

There are several specific situations within haematuria management:

Positive urine culture

Haematuria with a positive urine culture in females requires treatment with culture specific antibiotics. Haematuria in similar circumstances in the male always requires referral. Microscopic haematuria in females with recurrent UTIs also requires investigation as per protocol.

Microscopic haematuria

It must be noted that a single episode of microscopic haematuria with any risk factor for malignancy will mandate cystoscopy, imaging and cytology. Determination that there is a low risk of malignancy does not mandate all of these. In this case, imaging is usually performed of the upper tract, followed by flexible cystoscopy if abnormalities are found.

Ideally, all patients who are high risk should have an intravenous urogram and an ultrasound, as there is a risk of missing a cancer if only one is used.

Learning bite

A male with features of UTI and haematuria on dipstick should be followed up urologically and not merely given culture sensitive antibiotics.

Gross haematuria

Gross haematuria can lead to clot retention and severe abdominal discomfort. The patient may require resuscitation and haematological investigations including FBC, clotting and cross match. This condition requires irrigation with a three way large haematuria catheter, until the urine is clear, and subsequent cystoscopy. Failure to clear the urine through bladder washout will require a continuous infusion through one of the ports on the catheter.

Macroscopic haematuria

Macroscopic haematuria has a high diagnostic yield for urological malignancy. In men over 60 the positive predictive value for macroscopic haematuria for malignancy is 22.1% [10].

Learning bite

Intravenous urogram (IVU), ultrasound, cystoscopy and cytology are required to rule out sinister causes of haematuria.

Intractable haematuria

Intractable haematuria can occur in radiation cystitis, bladder carcinoma and cyclophosphamide.

Renal biopsy

The role of renal biopsy in patients with isolated haematuria is not yet clearly understood. There are structural glomerular abnormalities in many of these patients, but they appear to be at low risk for progressive disease [8].

Patients with microscopic haematuria, proteinuria (500 mg or more on 24 h collection), casts, dysmorphic red blood cells or elevated serum creatinine should be referred to nephrologists for a renal biopsy. It is unusual for haematuria of a surgical/urological cause to produce protein concentration >200 mg/dl. The management of nephrological diseases will depend on the specific findings of biopsy.