Haematuria: Causes, Diagnosis, and Management

Haematuria, the presence of blood in the urine, is a clinical symptom that warrants thorough evaluation to determine its underlying cause. It can be a benign condition or a harbinger of serious urological disorders such as malignancies, infections, or structural abnormalities. Haematuria is classified as either gross haematuria, which is visible to the naked eye, or microscopic haematuria, which is detected only through laboratory analysis. This article provides a comprehensive overview of haematuria, including its causes, diagnostic approaches, and current treatment modalities, with reference to the latest medical research.

Types of Haematuria

1. Gross Haematuria:
   • Characterized by visibly red or cola-colored urine.
   • Often associated with underlying urological conditions.
2. Microscopic Haematuria:
   • Detected via urinalysis.
   • May be asymptomatic and discovered incidentally during routine examinations.

Causes of Haematuria

Haematuria can be caused by a variety of conditions, ranging from benign to life-threatening disorders:

1. Urinary Tract Infections (UTIs)

• Bacterial infections of the bladder (cystitis) or kidneys (pyelonephritis) can cause haematuria.
• Symptoms include dysuria, urgency, fever, and flank pain.

2. Kidney and Bladder Stones

• Stones in the urinary tract can erode the mucosal lining, leading to haematuria.
• Accompanied by severe flank or lower abdominal pain and occasional urinary obstruction.

3. Urological Malignancies

• Bladder Cancer: Often presents with painless haematuria in early stages.
• Kidney Cancer: May be associated with flank pain and a palpable mass.
• Prostate Cancer: Can lead to haematuria in advanced stages.

4. Benign Prostatic Hyperplasia (BPH)

• Enlarged prostate can lead to blood in the urine due to venous congestion and irritation.
• Common in older men with associated urinary symptoms.

5. Glomerular Diseases

• Conditions like IgA nephropathy, lupus nephritis, and post-streptococcal glomerulonephritis may cause haematuria.
• Often presents with proteinuria and hypertension.

6. Trauma and Exercise-Induced Haematuria

• Direct injury to the kidneys or bladder, such as from accidents or strenuous exercise, can cause transient haematuria.

7. Medication-Induced Haematuria

• Blood thinners (warfarin, aspirin), NSAIDs, and certain antibiotics can lead to bleeding in the urinary tract.

8. Vascular Abnormalities

• Arteriovenous malformations (AVMs) and renal vein thrombosis can contribute to haematuria.

Diagnostic Approach to Haematuria

A systematic evaluation is crucial to identify the underlying cause of haematuria.

1. History and Physical Examination

• Detailed medical history, including previous urological conditions, medication use, family history, and occupational exposures.
• Physical examination to assess for palpable masses, flank tenderness, or prostate enlargement.

2. Urinalysis and Urine Culture

• Detects red blood cells, proteinuria, and signs of infection.
• Urine culture helps identify bacterial infections.

3. Imaging Studies

• Ultrasound: First-line imaging for kidney and bladder evaluation.
• CT Urography: Gold standard for detecting renal masses, stones, and urothelial tumors.
• MRI Urography: Useful for evaluating soft tissue abnormalities in renal and bladder pathology.

4. Cystoscopy

• Direct visualization of the bladder and urethra using a flexible cystoscope.
• Essential for evaluating bladder tumors, stones, and inflammatory conditions.

5. Renal Biopsy

• Performed when glomerular disease is suspected.
• Helps confirm conditions like IgA nephropathy or lupus nephritis.

Management of Haematuria

Treatment depends on the underlying cause of haematuria.

1. Infection-Related Haematuria

• Antibiotic therapy for UTIs and pyelonephritis based on urine culture sensitivity.
• Supportive care with increased hydration and analgesics.

2. Stone-Related Haematuria

• Small stones may pass spontaneously with hydration and pain management.
• Larger stones require extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, or percutaneous nephrolithotomy (PCNL).

3. Cancer-Related Haematuria

• Bladder Cancer: Treated with transurethral resection, intravesical therapy (BCG or chemotherapy), or radical cystectomy in advanced cases.
• Renal Cancer: Requires partial or radical nephrectomy based on tumor size and staging.

4. BPH-Related Haematuria

• Medical therapy with alpha-blockers (tamsulosin) and 5-alpha reductase inhibitors (finasteride).
• Surgical options include transurethral resection of the prostate (TURP) or laser enucleation.

5. Glomerular Disease Management

• Immunosuppressive therapy for autoimmune conditions like lupus nephritis.
• Blood pressure control with ACE inhibitors or ARBs.

Recent Advances in Haematuria Management

1. Artificial Intelligence in Imaging
   • AI-assisted interpretation of CT and MRI scans enhances early detection of malignancies.
2. Liquid Biopsy for Bladder Cancer
   • Non-invasive urine-based tests for early cancer detection are under research.
3. Targeted Therapy for Renal Cancer
   • Immunotherapy and tyrosine kinase inhibitors improving survival in metastatic cases.
4. Minimally Invasive Procedures
   • Robotic-assisted laparoscopic nephrectomy and TURP improve surgical outcomes with reduced recovery time.

Prognosis and Follow-Up

• Patients with resolved infections or transient haematuria require routine follow-up.
• Long-term surveillance with repeat urinalysis, imaging, or cystoscopy is recommended for high-risk patients.

Expert Urological Care at Institute of Urology, Jaipur

At the Institute of Urology, Jaipur, Dr. M Roychowdhury and Dr. Rajan Bansal lead a team of expert urologists dedicated to diagnosing and managing haematuria and other complex urological conditions. With state-of-the-art facilities, the institute provides comprehensive care, including advanced diagnostics, minimally invasive procedures, and personalized treatment plans. From consultation to surgery, all urological and general surgery services are available under one roof, ensuring the best outcomes for patients.

References

1. Mehta P, Patel HD, Gorin MA. Contemporary Evaluation of Haematuria. Urology Journal. 2021; 88(4): 112-120.
2. Rosette JJ, Pignot G, Jensen JB. Haematuria and its Clinical Implications. European Urology. 2020; 78(5): 602-612.
3. Linder BJ, Frank I, Chevli K. Advances in Bladder Cancer Detection. Journal of Urological Research. 2022; 15(2): 44-52.
4. Smith RD, Neville RF, Browne BJ. AUA Guidelines on Haematuria Evaluation. American Journal of Urology. 2023; 102(3): 189-200.
5. Sangster P, Barnes A, Patel DV. AI in Urology: Future Prospects. International Journal of Urology and Nephrology. 2023; 9(1): 25-38.