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

Exclude UTI, contamination (by menstruation) and transient causes (e.g. exercise haematuria, myoglobinuria, calculi, rifampicin, doxorubicin)
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
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)
Gross, painless haematuria refer urgently to Haematuria Clinic on 2-week wait

Non-visible (microscopic) haematuria (NVH)

Assessment of patients with NVH should include the following:

Exclude UTI, contamination and other transient causes (as above)
Treat any UTI and obtain dipstick confirmation of no blood, leucocytes or nitrites after treatment; if negative on follow-up, no referral is required
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.

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

Nephrology referral

Nephrology referral is required if:

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

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.

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

Haematuria (blood in the urine)

Contents:

Classification of haematuria

Visible (macroscopic) haematuria (VH)

Non-visible (microscopic) haematuria (NVH)

Nephrology referral

The Fast-Track Haematuria Clinic

Long-term monitoring

Fast-Track referral forms (medical staff only)

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