Haematuria (blood in the urine)

Summary: Initial assessment of significance of haematuria is vital

Advice: Please see agreed policy document for haematuria guidelines Refer To: PLease see above policy document

Contents:

Classification of haematuria

Haematuria is most usefully divided into:

  1. Visible (macroscopic) haematuria (VH)
  2. Non-visible (microscopic) haematuria (NVH)

Urine microscopy is not reliable in detecting NVH so it is not necessary to confirm NVH in the laboratory.

The overall risk of bladder cancer is:

  • 24% in patients with VH
  • 4% in patients with NVH

The overall prevalence of NVH in the population is in the order of 5% but NVH has only a 0.5% positive predictive value (PPV) for bladder cancer

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Visible (macroscopic) haematuria (VH)

Assessment of patients with VH should include the following:

  • Exclude UTI, contamination (by menstruation) and transient causes (e.g. exercise haematuria, myoglobinuria, calculi, rifampicin, doxorubicin)
  • For a single episode of VH, treat any UTI and obtain dipstick confirmation of no blood, leucocytes or nitrites after treatment; if negative on follow-up, no referral is required
  • Refer patients aged 45 and over with unexplained visible haematuria in the absence of a urinary tract infection, to the haematuria clinic on a 2WW basis
  • Refer patients aged 45 and over with visible haematuria that persist or recurs after successful treatment of a urinary tract infection to the haematuria clinic on a 2WW basis
  • Patients not fulfilling the above criteria should be referred to the Urology Outpatient Clinic if there is ongoing clinical concern

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Non-visible (microscopic) haematuria (NVH)

Assessment of patients with NVH should include the following:

  1. Exclude UTI, contamination and other transient causes (as above)
  2. Treat any UTI and obtain dipstick confirmation of no blood, leucocytes or nitrites after treatment;  if negative on follow-up, no referral is required
  3. Refer patients aged 60 and above with non-visible haematuria AND either dysuria or an elevated serum white cell count to the haematuria clinic on a 2WW basis
  4. If asymptomatic and persistent (2 of 3 dipsticks positive, done at weekly intervals within a month ) , suspect intrinsic renal disease and refer to nephrology if one or more of the following are found (especially if patient is < 50 years):
  • Evidence of declining GFR: by > 10 ml/min at any stage within the last 5 years or by > 5 ml/min within the last year.
  • Stage 4 or 5 CKD (chronic kidney disease): eGFR < 30 ml/min.
  • Isolated haematuria (ie in the absence of significant proteinuria) with hypertension in those aged < 40 years.
  • Patients not fulfilling the above criteria should be referred to the Urology Outpatient Clinic if there is ongoing clinical concern

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Nephrology referral

Nephrology referral is required if:

  1. Any one of the initial investigations listed above is abnormal
  2. Declining eGFR (>10 ml/min over 5 years or >5 ml/min over 1 year
  3. Stage 4 or 5 CKD with eGFR less than 30ml/min
  4. Isolated NVH with hypertension, especially if less than 40 years
  5. VH coinciding with intercurrent (usually respiratory) infection
  6. Patient less than 16 years

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The Fast-Track Haematuria Clinic

Fast-Track assessment for haematuria is performed on a one-stop basis and will involve:

  • a full clinical history
  • a full clinical examination (including DRE)
  • urinary tract imaging (ultrasound or CT scanning)
  • urine cytology (which does not need to be performed in primary care)
  • flexible cystoscopy under local anaesthetic

At the end of the consultation, a management plan will be agreed with the patient, if further treatment is necessary. Patients in whom no abnormality is found will be given appropriate advice on how to monitor their symptoms.

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Long-term monitoring

If referral is not indicated, regular monitoring should be performed but referral should be considered in the event of:

  • a-NVH becoming s-NVH -> Haematuria Clinic
  • development of voiding LUTS -> Haematuria Clinic
  • development of VH -> Haematuria Clinic
  • significant or increasing proteinuria -> nephrology
  • falling eGFR -> nephrology
  • hypertension -> nephrology

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Fast-Track referral forms (medical staff only)

 

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Related Downloads

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Information Sheets

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