Blood in Urine

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May be present as intact RBC which indicates bleeding or discoloration. Note that a very small amount of blood is enough to give the entire urine sample or the foley bag a red/pink hue, and it is difficult to judge the amount of bleeding from a gross examination. The urine color may also be red due to excretion of pigment such as myoglobin and hemoglobin, in which case the urine dipstick shows presence of blood but there are no RBC seen on microscopic examination. Always check INR/PT/PTT and send a fresh urine sample for urinalysis when blood is detected. A case can also be made for urine cytology, especially for elderly patients.

Hematuria, or blood in the urine, can be either gross (visible) or microscopic (as defined by more than three to five red blood cells per high power field when viewed under magnification). Gross hematuria can vary widely in appearance, from light pink to deep red with clots. Despite the quantity of blood in the urine being different, the types of conditions that can cause the problem are the same, and the workup or evaluation that is needed is identical.

People with gross hematuria usually present to their doctor with this as a primary complaint. Microscopic hematuria, on the other hand, is most commonly detected as part of a periodic checkup by a primary-care physician.

The causes of gross and microscopic hematuria are similar and may result from bleeding anywhere along the urinary tract. One cannot readily distinguish between blood originating in the kidneys, ureters (the tubes that transport urine from the kidneys to the bladder), bladder, or urethra. Any degree of blood in the urine should be fully evaluated by a physician, even if it resolves spontaneously.

Test results
Infection of the urine, stemming either from the kidneys or bladder, is a common cause of microscopic hematuria. Kidney and bladder stones can cause irritation and abrasion of the urinary tract, leading to microscopic or gross hematuria. Trauma affecting any of the components of the urinary tract or the prostate can lead to bloody urine. Hematuria can also be associated with renal (or kidney) disorder, as well as hematologic diseases involving the body's clotting system. Medications that increase the risk of bleeding, such as aspirin, warfarin (Coumadin), or clopidogrel (Plavix), may also lead to bloody urine. Lastly, cancer anywhere along the urinary tract can present with hematuria.

Also you should know
Lower urinary tract symptoms, such as urgency (feeling a strong need to urinate) and frequency (needing to urinate frequently), as well as the presence of fever and/or chills are suggestive of infection. Recent trauma, even if believed by the patient to have been inconsequential, should be considered as a potential cause. Abdominal and/or flank pain, especially if radiating to the inguinal or the genital area, may suggest kidney stones. All recent medications, including vitamins or herbal supplements, should be reviewed with the health-care provider. However, it is important to note that even if the patient has been taking a medication that is associated with bleeding, a full workup (as listed below) should still be undertaken.

The physical exam will focus on possible sources of hematuria. Bruising over the back or abdomen may indicate trauma. A digital rectal exam should be performed, as findings consistent with prostatitis (for example, tenderness on palpation of the prostate) or an enlarged prostate (suggestive of BPH or benign enlargement of the prostate gland) may be useful in making a diagnosis. A repeat urinalysis, as well as a urine culture, should be obtained. The presence of white blood cells on urinalysis is more consistent with a urinary tract infection. Protein, glucose, or sediment in the urine may indicate the presence of a disorder of the kidneys. Blood tests are also important, as they will aid in assessing renal function and identifying any clotting abnormalities.

In addition to the basic history and physical exam, there are three additional components for any workup of hematuria: CT scan, urine cytology, and cystoscopy.

The CT scan is an imaging evaluation of the urinary tract. Prior to the procedure, the patient drinks an oral contrast agent and a dye is injected intravenously. The patient then goes through the CT scan machine and images are taken of the abdomen and pelvis. Another test that can be performed, the intravenous pyelogram (IVP), is also a type of X-ray evaluation of the urinary tract. In this procedure, a dye is injected into the veins, and this is filtered by the urinary tract. A series of X-rays are then taken over a 30-minute period to look for abnormalities. The CT scan is more commonly performed than the IVP to evaluate the urinary tract and should be considered the test of choice. Both of these studies are especially useful for evaluating the kidneys and ureters but not the bladder, prostate, or urethra. Therefore, a second examination called a cystoscopy is necessary. This is a simple 10-minute procedure wherein a thin, flexible cystoscope (or fiberoptic camera) is inserted via the urethra into the bladder in order to directly visualize any lesions or sources of bleeding. This is usually done with local anesthetic jelly injected into the urethra. Finally, urine cytology involves giving a urine sample to be analyzed by a pathologist for the presence of cancerous or abnormal-appearing cells.

All information on this page is intended for your general knowledge only and does not provide medical advice, diagnosis or treatment.