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


Classification of haematuria

Haematuria is most usefully divided into:

  1. Visible (macroscopic) haematuria (VH)
  2. Non-visible (microscopic) haematuria (NVH)
    • symptomatic (s-NVH) e.g. associated with LUTS, frequency, dysuria, loin pain, suprapubic pain
    • asymptomatic (a-NVH)

NVH is defined as >=1+ on dipstick (no distinction needs to be made between haemolysed or non-haemolysed blood). A trace of blood only on dipstick is not regarded as significant.

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
  • 9.4% 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:

  1. Exclude UTI, contamination (by menstruation) and transient causes (e.g. exercise haematuria, myoglobinuria, calculi, rifampicin, doxorubicin)
  2. For a single episode of painful 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
  3. For recurrent or persistent UTI with VH, refer urgently to Haematuria Clinic on 2-week wait (5% of patients with bladder cancer present with recurrent UTI)
  4. Gross, painless haematuria refer urgently to Haematuria Clinic on 2-week wait

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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. 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.
  1. If all the investigations above are normal:
    • for persistent a-NVH less than 50 years, monitor but refer to Urology Outpatients  if there are risk factors for bladder cancer (e.g. smoking, occupational exposure, carcinogens or cyclophosphamide)
    • for persistent a-NVH greater than 50 years, refer urgently to Haematuria Clinic on 2-week wait
    • for s-NVH any age , refer urgently  to Haematuria Clinic on 2-week wait

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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)
  • blood tests, including PSA (which does not need measurement in primary care)
  • urinary tract imaging (ultrasound, IVU 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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