SU29.1 | Hematuria Evaluation — Summary & Reflection

KEY TAKEAWAYS

Haematuria is red cells in the urine; classify it as visible (macroscopic) or non-visible (microscopic), and by stream timing as initial (urethra/prostate), terminal (bladder neck/trigone) or total (bladder or upper tract). The cardinal rule is that painless visible haematuria is urological malignancy until proven otherwise and demands a complete work-up. Causes run by anatomical level — renal (RCC, calculi, trauma, glomerular), ureteric (calculi, TCC), bladder (TCC, the commonest painless cause; cystitis; calculi; schistosomiasis → SCC) and prostate/urethra (BPH, carcinoma, stricture, trauma) — and cut across a divide between surgical (urological) bleeding (isomorphic cells, clots, no casts) and medical (glomerular) bleeding (dysmorphic cells, red-cell casts, proteinuria → nephrology). Exclude pseudohaematuria (beetroot, rifampicin, myoglobinuria, haemoglobinuria) first. Investigate in order — urinalysis/microscopy, cytology, bloods/renal function, CT urogram (imaging of choice for the upper tract) and flexible cystoscopy (gold standard for the bladder). Management means treating the cause (TURBT for bladder TCC, nephrectomy for RCC, stone-directed therapy, TURP for BPH after excluding cancer), but only after the work-up is complete; never reassure a painless visible bleed on one normal test.

REFLECT

Recall a patient you have seen, or imagine clerking one in your next clinic, who reports blood in the urine. Did you establish whether it was visible or non-visible, painful or painless, and where in the stream the blood appeared — and did you actively ask about smoking and occupational exposures? Now consider the discipline this topic demands: if the bleed was painless and visible, would you have resisted the temptation to be reassured by a normal dipstick or a settled patient, and would you have arranged both a CT urogram and a cystoscopy? Reflect on how distinguishing surgical from medical haematuria at the microscope — looking for red-cell casts and dysmorphic cells — changes who you refer to urology and who you refer to nephrology, and how confidently you could explain that pathway to the patient in front of you.