Haematuria (Blood in Urine)

Overview

Haematuria means blood in the urine. It is divided into:

• Visible haematuria (macroscopic or gross haematuria) — blood that discolours the urine and is obvious to the naked eye, ranging from pink to red to dark brown
• Non-visible haematuria (microscopic or dipstick haematuria) — blood detected only on urine testing, not visible to the eye

Haematuria is a symptom, not a diagnosis. It can arise from anywhere in the urinary tract — the kidneys, ureters, bladder, prostate, or urethra — and the causes range from entirely benign to serious. The important principle is that haematuria should always prompt investigation to identify or exclude a significant underlying cause.

All cases of visible haematuria should be referred for urological assessment. Non-visible haematuria in certain higher-risk groups (older age, smokers, occupational chemical exposure) also requires investigation. A single episode is sufficient reason for referral.

Symptoms

Haematuria itself is the primary symptom. Associated features can help suggest the underlying cause:

• With dysuria and frequency — urinary tract infection is likely; urine culture should be sent and antibiotics prescribed; haematuria that persists after treatment of infection requires further investigation
• With loin-to-groin pain — ureteric colic from a kidney or ureteric stone is the likely cause
• Painless — particularly concerning for bladder or kidney cancer; requires prompt investigation
• At the start of the urinary stream — may originate from the urethra or prostate
• Throughout the stream or at the end — more likely to arise from the bladder or upper urinary tract

Diagnosis

The haematuria investigation pathway typically includes:

• Urine dipstick and microscopy — to confirm the presence of blood and exclude infection
• Urine culture — to identify or exclude urinary tract infection
• Blood tests — including full blood count, kidney function (creatinine), clotting screen if anticoagulated
• Flexible cystoscopy — direct endoscopic inspection of the bladder, performed under local anaesthetic in the outpatient setting; identifies bladder tumours, stones, or inflammation
• CT urogram (CTU) — a CT scan with intravenous contrast that images the upper urinary tract (kidneys and ureters) as well as the bladder; the standard imaging investigation for haematuria

Many urology services offer a one-stop haematuria clinic, where cystoscopy and other assessments are coordinated in a single visit to minimise delays and provide reassurance or a diagnosis efficiently.

Treatment

Treatment depends entirely on the underlying cause identified through investigation:

• Urinary tract infection — appropriate antibiotic treatment; haematuria should be rechecked after treatment
• Kidney or ureteric stones — managed according to size and location (see kidney stones section)
• Bladder tumour — TURBT and further management depending on stage and grade
• Kidney tumour — referred to specialist renal oncology team
• Benign prostatic enlargement — treated as for BPH (see BPH section)
• No cause found — a significant proportion of patients investigated for haematuria have no cause identified; these patients are reassured but should be advised to re-present if haematuria recurs, and may require ongoing surveillance

Prompt investigation of haematuria allows serious causes to be identified and treated at an early stage, when outcomes are more favourable.