For the SHO, the first step is not to diagnose the exact cause immediately, but to decide whether this is an acute presentation needing inpatient management or a stable presentation needing outpatient haematuria investigation.

• Non-visible haematuria (nVH), also known as microscopic haematuria, is the presence of blood in the urine that can only be detected on dipstick or microscopy. It is a common incidental finding that may require further investigations to assess for urological malignancy.

• Patients presenting with nVH are more commonly those with urinary tract stones and infections, but can still indicate a more sinister pathology, that in some cases, may warrant OP investigation (see NICE guidance).

History

1Presenting complaint:

• Visible vs non-visible?
  • If visible - how many instances?
  • If nVH – how was this discovered?
• Any triggers or obvious causes of haematuria?
• Timing: throughout stream (bladder/upper tract) vs initial/terminal (prostatic/urethral)
• Presence of clots – suggests significant bleeding (further read HERE)
• Pain – think acute cause
  • Suprapubic – cystitis, retention
  • Loin pain – stones, pyelonephritis
• LUTS – storage and/or voiding symptoms
• Menstrual history in women

2Relevant past medical history:

• Previous surgery/instrumentation/trauma to the urinary tract
• History of pelvic irradiation, cyclophosphamide use (risk of bladder cancer)
• Anticoagulant/antiplatelet use

3Social history:

• Smoking status (key risk factor)
• Occupational exposure (dyes, rubber)
• Illicit drug use – especially ketamine

4Exclude transient causes:

• UTI (treat and repeat dipstick after 4 – 6 weeks)
• Menstruation
• Vigorous exercise

Examination

• Observations
• Abdominal examination — palpable bladder, loin tenderness, masses
• External genitalia
• DRE
• Assess hydration and haemodynamic stability

Investigations

General

• BP check (renal disease)
• Urine Dipstick: Confirm presence of blood (1+ or more). Check for protein (renal disease) or nitrites/leukocytes (infection)
• Bloods: U&Es, FBC, clotting if relevant
• PSA – if appropriate and after patient counselling

Specialist

Non-acute patients are usually seen in a “Haematuria clinic” or “One-stop clinic”.

If patients are referred for specialist investigations they will have both assessment of upper tracts (kidney, ureter) and lower tract (bladder, prostate, urethra).

First decide:

1. Visible or non-visible?
2. Painful or painless?
3. Is the patient acutely unwell or obstructed?

PAINFUL haematuria

Think of acute causes and manage accordingly:

• Loin pain → ureteric stone / pyelonephritis
• Dysuria, fever, rigors → UTI / pyelonephritis / sepsis
• Suprapubic pain with clots and poor catheter drainage → clot retention (read HERE)
• Recent trauma/instrumentation → traumatic bleeding

Treat the underlying cause, resuscitate if needed, give antibiotics if infection, and escalate early if septic, obstructed, bleeding heavily or in retention.

PAINLESS haematuria

Painless visible haematuria is malignancy until proven otherwise.

If the patient is stable and well, is passing urine and haematuria is not significant, this is usually investigated as an outpatient through a Haematuria clinic.

Otherwise – if patient has significant haematuria, clot retention or is unwell – they will require inpatient admission + 3-way catheter and bladder washout. Read further management – HERE