16. Haematuria: Evaluation and Management

Karl H. Pang¹ and James W. F. Catto^{2, 3}

(1)

Department of Oncology and Metabolism and Academic Urology Unit, University of Sheffield, Sheffield, UK

(2)

Department of Urological Surgery, Academic Urology Unit, University of Sheffield, Sheffield, UK

(3)

Department of Urology, Royal Hallamshire Hospital, Sheffield, UK

James W. F. Catto

Email: j.catto@shef.ac.uk

Email: j.catto@sheffield.ac.uk

Keywords

HaematuriaVisible haematuriaNon-visible haematuriaAsymptomatic microscopic haematuria

Introduction

It is estimated that 2.5% of the population have non-visible haematuria (NVH) if tested and consequently haematuria accounts for approximately 20% of urological referrals [1]. Around 40% of patients investigated for haematuria have an underlying pathology, with around half attributed to urological malignancy [2]. The nature, severity and potential causes need careful assessment during consultation and investigated and managed appropriately. Most cases are investigated and managed in the out-patient setting, however, in extreme cases, admission and acute management with blood transfusion, catheterisation of the bladder, washout and irrigation may be required.

Definition and Classification of Haematuria

Haematuria occurs when there are red blood cells (RBC) in the urine. This can be classified into Visible Haematuria (VH: previously termed frank, gross or macroscopic haematuria) or NVH (detected by microscopic examination of urine or dipstick analysis) [3]. In addition, haematuria can be symptomatic or asymptomatic. The dipstick method to detect haematuria is based on the oxidation of a chromogen by the presence of haemoglobin, producing a degree of indicator colour change proportional to the degree of haematuria. The dipstick method has a sensitivity of 95% and a specificity of 75% and positive tests need to be confirmed with microscopy. Microscopic haematuria is commonly defined as ≥3 RBC per high powered field (HPF) on one sample (American Urological Association (AUA) guidelines) or on two samples (Canadian Urological Association (CUA) guidelines). None of the European guidelines comment on the degree of haematuria on microscopy [4]. Dipstick specificity is limited due to other peroxidases or oxidizing agents such as myoglobin and Vitamin C (these lead to false positive tests).

Aetiology of Haematuria

Bleeding into urine may occur from intrinsic renal pathologies (affecting filtration in the glomerular or damage to the tubules) or from benign and malignant pathologies in the post-renal urinary tract (renal pelvis to the urethra, Fig. 16.1):

../images/142736_2_En_16_Chapter/142736_2_En_16_Fig1_HTML.png — Fig. 16.1

NICE referral criteria and subsequent urological evaluation of haematuria. *NICE* National Institute for Health and Care Excellence, *LUTS* lower urinary tract symptoms, ED erectile dysfunction, *DRE* digital rectal examination, *UTI* urinary tract infection, *PCa* prostate cancer, *BCa* bladder cancer, *RCa* renal cancer, *UCC* urothelial cell carcinoma, *AUA* American Urological Association

Urological Malignancy

Haematuria is an important symptom of renal cancer (RCa), upper tract urothelial cell carcinoma (UCC) and bladder cancer (BCa) [4, 5]. Painless haematuria is considered the cardinal symptom of bladder cancer. Advanced prostate cancer (PCa) may cause VH but is usually detected through other symptoms. The risks of cancer vary with extent of haematuria, patient age and sex. Around 14% of patients with VH have cancer, compared to 3.1% with NVH [2]. The risks are lower in younger populations. For example, in patients under 45 years old, the risk of cancer with VH is 3.5% versus 0.5–1.1% for NVH [2].

Infection and Inflammation

Urinary tract infections (UTIs) usually present with local symptoms (cystitis or pyelonephritis) but often have NVH or even VH . It is uncommon for men to have ascending UTI of the upper tracts, but prostatitis can occur as a primary infection or as a complication of prostate biopsy. In younger patients with infection, potential underlying sexually-transmitted infections (STI) need to be explored.

Non-infective inflammatory conditions such as interstitial cystitis can cause haematuria and require cystoscopic evaluation with hydrodistension (glomerulation and Hunner’s ulcers) and biopsy (mast cells) for a definitive diagnosis. Haemorrhagic cystitis secondary to radiotherapy and chemotherapy will result in haematuria. Benign prostate hyperplasia (BPH) and post- transurethral resection of the prostate (TURP) regrowth/inflammation of the prostate cavity is a common cause of haematuria in older men.

Urolithiasis

Urinary tract stones can be asymptomatic or present acutely with painful ureteric colic. Most patients will have NVH if tested. Exceptions include upper tracts obstructed by ureteric stones, this could be complicated by infection and urosepsis.

Non-urological Causes of Haematuria

Patients under the age of 45 years with asymptomatic NVH are more likely to have intrinsic renal pathology such as IgA nephropathy (Berger’s disease), thin glomerular basement membrane disease or hereditary nephritis (Alport’s syndrome). Hypertension, urinary red cell casts, dysmorphic RBC and significant proteinuria is suggestive of a glomerular cause of haematuria.

Other potential non-urological causes of haematuria include haematological pathologies such as thrombocytopenia purpura. Bleeding from the gynaecological system resulting in contamination of the urine can occur, this could be benign in origin, such as normal menstruation, or secondary to gynaecological malignancy. Intensive exercise with or without trauma can cause haematuria [6]. Other spurious causes of haematuria include foods (beetroot and blackberries), drugs (rifampicin and chloroquine) and rhabdomyolysis.

Evaluation of Haematuria

Various international guidelines suggest pathways to investigate haematuria, including the National Institute for Health and Care Excellence (NICE), British Association of Urological Surgeons (BAUS), AUA, CUA and European Association of Urology (EAU) guidelines [4].

Guidelines on Investigating Haematuria

The 2015 NICE guidelines (adopted by BAUS 2016) recommend referring patients with a suspicion of renal/bladder malignancy on a suspected cancer pathway referral (appointment within 2 weeks) if they are aged 45 years and over and have unexplained VH without UTI or VH that persists or recurs after successful treatment of UTI (Fig. 16.2). NICE also recommends referring those who are aged 60 years and over and have unexplained NVH and either dysuria or a raised serum WCC. Patients aged 60 years and over with recurrent or persistent unexplained UTI suspicious for BCa can be referred on a non-urgent basis [5, 7]. In contrast, the 2012 AUA (reviewed 2016) and 2015 CUA recommend cystoscopy for asymptomatic NVH in patients aged 35 years and older [8, 9]. Whilst the Dutch guidelines recommends investigating asymptomatic NVH in older patients aged 50 years and over [4].

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Tags: Urologic Principles and Practice

Mar 7, 2021 | Posted by admin in UROLOGY | Comments Off

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