A patient with blood in their urine

When did you first notice blood in your urine?/ What colour has your urine been?

“My urine has probably been pinkish for the past week, but over the last 24 hours it has been dark red”

Are you able to pass urine? When did you last pass urine?

“It’s becoming difficult, I feel like I have to force the urine out and my tummy is becoming uncomfortable. I went for a wee last night, but couldn’t this morning.”

Have there been blood clots in your urine?

“Yes, I have been passing blood clots”

Have you had a fever or any burning/stinging when you pass urine?

“No”

Do you have any pain elsewhere, like in the sides of your tummy or back (flank pain)?

“No”

Prior to this did you suffer from any frequency, urgency or nocturia?

“No”

Do you have any history of recent trauma that may have caused this, such as falling over and landing on your side?

“No”

Past medical and surgical history

• Do you have any other medical conditions?

Specifically, ask:

• Do you have a history of urinary tract stones?
• Have you ever previously had urological cancer?
• Have you previously had any surgery on your kidneys, bladder or prostate?

“I have high blood pressure, but other than that have no other medical problems”

Medication history/allergies:

• Do you take any regular medication?

Specifically, ask:

• Do you take any anticoagulants or antiplatelets? (important to know due to the increased risk of bleeding)
• Do you have any allergies?

“I just take a tablet for my blood pressure, it is well controlled”

Family history

• Do you have any family history of urinary tract stones?
• Do you have any family history of bladder, renal or prostate cancer?
• Do you have any family history of polycystic kidney disease?
• Any other illnesses in the family?

“No”

Social history

• Have you ever smoked? How many cigarettes do/did you smoke a day? How long for?
• What is your level of alcohol intake?
• Do you regularly take any illicit substances?
• What do you do for a living?
• Have you ever worked in industries that expose you to dye, paints, rubber, leather or textile production?
• Have you ever travelled to, or lived in Africa, Asia or South America?

“I’ve been a smoker since I was 20 and usually smoke 20 cigarettes a day (35 pack-years). I drive a black cab for a living and only travel to my holiday home in Spain”

Bladder cancer has a strong association with smoking.  There is also convincing evidence of increased risk of bladder cancer in those with occupational exposure to paints, rubber production and dyes. There is limited evidence of increased risk of bladder cancer in hairdressers, barbers and textile production.  In regions with endemic Schistosoma haematobium, there is an increased risk of squamous cell carcinoma of the bladder.

• Palpate for any cervical lymphadenopathy (associated with advanced renal cell carcinoma)
• Perform an abdominal examination to assess for any flank or suprapubic tenderness, ballot for kidney masses and percuss the bladder to assess fullness. See the Geeky Medics guide to performing a comprehensive abdominal examination here.
• Examine external genitalia for evidence of a non-reducing varicocele. Note any blood and/or clots at the urethral meatus. See the Geeky Medics guide to testicular examination here.
• Perform a digital rectal examination to assess the prostate’s size, tenderness and/or abnormal cragginess. See the Geeky Medics guide here.

Examination findings

• The bladder is palpable
• Examination is otherwise unremarkable

Urine for MC&S should be sent to rule out an infective cause of haematuria.

Blood tests including FBC, U&E, CRP, coagulation and Group and Save are useful. Patients who have a low haemoglobin level may require transfusion. Any clotting abnormalities need to be corrected. Raised inflammatory markers may suggest an infective cause of haematuria.

A bladder scan would be helpful in assessing evidence of clot retention. Patients who are haemodynamically stable, able to pass urine, and have minimal or no detectable clots may be discharged from A&E and managed in the outpatient setting under the 2-week wait (2ww) haematuria pathway.

Findings

Bedside urine dipstick was positive only for blood (4+).  Blood tests were unremarkable with normal haemoglobin (145 g/dL).  Bladder scan revealed 300ml residual volume.

Urological malignancy

• Bladder cancer:
  • Transitional cell carcinoma is the most common type in the UK
  • Squamous cell carcinoma is more common in regions with endemic Schistosoma haematobium
• Renal cancer:
  • Renal cell carcinoma
  • Transitional cell carcinoma
• Prostate cancer

Infection/inflammation

• Urinary tract infection
• Pyelonephritis
• Prostatitis
• Cystitis
• Urethritis
• Less common infections (e.g. hepatitis, tuberculosis, schistosomiasis)

Other urological causes

• Stones (kidney, ureter, bladder)
• Benign prostatic hyperplasia
• Polycystic kidney disease
• Trauma
• Recent genito-urinary surgery

Other non-urological causes

• Blood disorders (sickle cell disease, clotting disorders)
• Drugs (anticoagulants, antiplatelets)
• Endometriosis (women)
• Exercise-induced haematuria
• Benign urine discolouration (beetroot, jaundice, food colourings, rifampicin, rhabdomyolysis)

Bladder cancer

As this patient appears to be in clot retention with a palpable bladder, immediate management would involve the insertion of a 3-way catheter, bladder washout and ongoing bladder irrigation.

If haemoglobin is less than 70 g/dL or the patient is haemodynamically unstable, they should receive a blood transfusion (and ongoing ABCDE assessment to stabilise them).

If a palpable flank mass, flank tenderness or intractable bleeding are present then an urgent CT urogram should be performed. Urology referral should be urgently sought.

In some patients, a cystoscopy and bladder washout under general anaesthetic may be required if haematuria persists, in spite of irrigation, or if large clots are identified on imaging. Patients whose haematuria settles with irrigation may be discharged for urgent outpatient investigation of haematuria under the 2ww pathway.

2ww haematuria clinic consisting of CT urogram to look for upper urinary tract causes of haematuria and direct visualisation of the bladder with cystoscopy to look for bladder cancer.  Cystoscopy of the bladder is required for the diagnosis of papillary bladder cancer, normal imaging does not rule out bladder cancer.

Urine cytology may be used as an adjunct. Positive urine cytology can indicate a tumour anywhere in the urinary tract. Negative cytology does not exclude malignancy.