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Blood in the urine (haematuria)


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What should I do if I have blood in my urine?

If you see blood in your urine, with or without symptoms of cystitis, you should contact your GP immediately for further advice

Your GP will normally investigate blood in the urine as a matter of urgency. Most GPs will perform some simple, baseline tests. You may be started on antibiotics to treat a presumed infection. However, if the urine test result comes back showing no evidence of infection, you will normally be referred to your local urology department for more detailed investigations using the "2-week wait" (fast-track) system.

What are the facts about blood in the urine?

  • the commonest cause of blood in the urine in the UK is infection (cystitis)
  • proven blood in the urine, whether visible or non-visible (found on a urine test), should always be investigated
  • 1 in 5 adults with visible blood in the urine and 1 in 12 adults with non-visible blood in the urine are subsequently discovered to have bladder cancer
  • children with blood in the urine rarely have cancer - they usually have infection in the bladder or inflammation of their kidneys (nephritis)
  • a "one-off" finding of a small trace of blood in the urine on routine testing may not be significant
  • some drugs (e.g. rifampicin, nitrofurantoin) and foodstuffs (e.g. beetroot) can turn the urine red

What should I expect when I visit my GP?

Your GP should work through a recommended scheme of assessment for patients with blood in the urine. This will normally include some or all of the following:

1. A full history

Your GP will ask you questions about any recent symptoms, any associated matters (including any drugs you are taking) and will enquire about smoking habits. Exposure to industrial chemicals or to substances that may be related to bladder cancer development are also important. You should inform your GP if you are taking blood-thinning drugs (warfarin, dicoumarin, rivaroxaban, prasugrel or dabigatran) or if you take anti-platelet treatment (aspirin, dipyridamole, clopidogrel). If the bleeding is painless and associated with clots of blood in the urine, it is likely that your GP will arrange urgent referral to a urologist.

2. A physical examination

A general physical examination will be performed, together with a rectal or vaginal examination. Your blood pressure may be measured as part of this examination.

 

3. Additional tests

The usual tests performed are:

a. General blood tests

The actual tests performed will be left to your GP's discretion. It is common to measure kidney function, clotting factors, prostate-specific antigen (PSA) and to check the blood cells for anaemia or other problems

b. Urine testing

A urine test will normally be sent for infection. Your GP may commence you on antibiotics whilst awaiting the result of this test. Fresh urine may also be sent to the laboratory for microscopic examination and to look for cancerous cells. Your GP may arrange a 24-hour urine collection to measure your urine protein levels

c. Other specific tests

Your GP may arrange an ultrasound scan of your kidneys and bladder, pictured right (or a CT scan of your abdomen) although this is usually performed in the urology department

 

What could have caused the blood in my urine?

50% (half) of patients with visible blood in the urine will have an underlying cause identified but, with non-visible blood in the urine, only 10% will have a cause identified

Although there are many potential causes for blood in the urine, those most often identified are:

  • bladder infection
  • cancers of the bladder (pictured), kidney or prostate
  • stones in the kidneys or bladder
  • inflammation of the kidneys (nephritis)
  • urinary tract injuries
  • blood disorders (e.g. sickle cell disease, clotting disorders, anticoagulant and anti-platelet drugs)
  • other causes, including less common infections (e,g. TB, schistosomiasis)

What happens next?

Your GP may decide that you do not require any further tests at this stage. In this case, you should have regular monitoring to assess the following, which may be signs that re-investigation is needed:

  • the development of other urinary symptoms
  • further episodes of blood in the urine
  • increasing levels of protein in your urine
  • progressive deterioration in your kidney function
  • the development of high blood pressure

Your GP will arrange urgent referral to the Haematuria Clinic of your local urology unit if:

  • you are over the age of 45 years, and have visible blood in the urine in the absence of infection
  • the blood fails to clear following antibiotic treatment for urinary infection
  • you have non-visible bleeding but significant urinary symptoms
  • you have non-visible bleeding, and you are over the age of 60 years with a high white blood count on a blood sample or discomfort when you are passing urine

This will involve a prolonged outpatient appointment when some or all of the following assessments will be performed: 

  • Detailed questioning about your urinary tract and any related symptoms
  • A physical examination (including rectal or vaginal examination)
  • Blood tests (if not already performed by your GP)
  • Examination of the urine for cancer cells
  • X-rays or scans (including)
    • CT scan - may involve an iodine-based injection; you must inform the staff if you have a history of allergy to iodine or to previous X-ray injections
    • ultrasound scan
    • intravenous urogram (IVU) - may involve an iodine-based injection; see allergy advice above.
  • A flexible cystoscopy

    This is a telescopic check of the bladder. It is performed under antibiotic cover & local anaesthetic using a small, flexible telescope which allows the clinic doctor to see inside your bladder (pictured).

Download an information leaflet about flexible cystoscopy.

If you have concerns about this, or have experienced problems with local anaesthetic in the past, you should ask about having your examination under a brief general anaesthetic (i.e. whilst you are asleep).

Download an information leaflet about examination under general anaesthetic.

When your tests have been completed, the medical staff will advise you on what to do next:

If an abnormality requiring further treatment is detected, the medical staff will advise you on what treatment is necessary and what this would involve (e.g. admission for telescopic removal of a bladder tumour, as shown in the video below, courtesy of Mr Nigel Bullock). 

Download an information leaflet about this procedure.

If no specific abnormality is found, you should report any further bleeding, or other urinary symptoms, to your GP who will be informed of the result of your assessment.

More resources on Blood in the urine (haematuria)

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