William Aiken

Seeing blood in the urine (haematuria) is always frightening, especially when it occurs for the first time. Haematuria is one symptom that should be taken seriously as it often heralds the presence of sinister or life-threatening disease arising from the urinary tract, especially in older persons. Its usual intermittent nature may fool one into a false sense of security while the underlying disease progresses.

Haematuria may be accompanied by pain or a burning sensation on passing urine and by pain in the abdomen or flank. The blood passed on urination may be noticed throughout, only at the beginning, or only at the end of the urine stream. In many cases, the blood in the urine may not be noticed at all but is found only on examination of the urine. Depending on the presence of pain or burning on urination and the point in the urine stream that the blood is noticed (beginning, throughout or end), the likely cause or origin of bleeding may be inferred with a fair degree of accuracy. The age, gender, occupation and smoking habit of the patient are also important clues to the likely cause of the bleeding.

Pepsi-coloured urine

It is important to distinguish haematuria caused by bleeding from the filtration system of the kidney (glomeruli and tubules) from haematuria caused by bleeding downstream of these structures, that is, the 'plumbing' such as the urethra, urinary bladder, ureters (the conduits that carries urine from the kidneys to the bladder), and so on. Bleeding caused by the former tends to result in 'pepsi-coloured' urine seen throughout the entire urinary stream and is often accompanied by impairment of kidney function and fluid retention resulting in swelling of the legs, puffy eyelids and high blood pressure.

This usually results from a condition called glomerulonephritis in which the glomeruli/tubules of the kidney become inflamed. Bleeding from the 'plumbing' of the urinary system usually results in bright red blood being seen in the urine and is not usually accompanied by kidney impairment or swelling of the body.

See your doctor fast

Common causes include bladder cancer, prostate cancer, kidney cancer, urinary tract stones, urinary tract infections, non-cancerous enlargement of the prostate gland (BPH, prostatitis), sickle cell disorder, and blood vessel abnormalities. An underlying bleeding tendency may aggravate bleeding from any of the above or may on its own also cause haematuria.

Immediate medical attention is necessary if blood is noticed in the urine. The doctor will take a careful history to determine if risk factors for serious underlying disease are present. Cigarette smoking, chronic exposure to certain chemicals found in the rubber, dyes, painting and textile industries, as well as certain types of chemotherapy received in childhood all put one at increased risk for bladder cancer. In most cases tests will be ordered and special imaging studies, such as ultrasound, will be requested. Urological referral is mandatory in all patients over 40 years and in any patient with risk factors for bladder cancer regardless of age.

An examination of the interior of the bladder (cystoscopy) is necessary regardless of what is seen on imaging tests to definitively rule out bladder cancer as a possible cause.

Apart from non-smoking sexually-active women younger than 40 years who develop haemorrhagic cystitis (bleeding caused by a severe bladder infection) in which symptoms of a urinary tract infection accompany the haematuria, antibiotics should never be prescribed for haematuria without also doing the necessary tests to rule out a sinister cause.

Haematuria requires prompt and careful evaluation and because of its usual intermittent nature, it should never be assumed that the underlying problem has resolved when the urine clears. Don't procrastinate with this symptom! Seek medical attention early.