Visible (gross) haematuria is urine that is visibly discoloured by blood or blood clot. It may present as urine that is red to brown, or as frank blood. As little as 1 mL of blood can impart colour to 1 litre of urine.
Visible haematuria, even when transient or asymptomatic, may indicate a significant disease process and always requires further investigation. The spectrum of aetiologies has a significant age-dependence, whereby the work-up of haematuria can differ between children, adults under the age of 35 years, and adults aged 35 years or older.
Patients with visible haematuria represent a higher-risk group for urological malignancy than those presenting with non-visible haematuria. Visible haematuria is a presenting sign in more than 66% of patients with urological cancer. The sensitivity of visible haematuria in revealing malignancy is significant: 0.83 for urothelial carcinoma of the bladder, 0.66 for ureteric carcinoma, and 0.48 in renal cell carcinomas. However, the oncological significance of visible haematuria is different for males and females. In men aged >60 years, the positive predictive value of visible haematuria for urological malignancy is 22.1%, and in women of the same age it is 8.3%.
Risk factors for urothelial carcinoma include:
Age 35 years or older
Exposures to benzene, aromatic amines, carcinogens, chemotherapy, or high doses of analgesics
A history of:
Irritative voiding symptoms
Chronic urinary tract infection
Indwelling urinary catheter
- Renal trauma
- Bladder trauma
- Urethral trauma
- Sickle cell anaemia
- Cystic renal disease
- Arteriovenous malformation
- Renal vein thrombosis
- Alport syndrome
- Extrapulmonary tuberculosis
- Benign familial haematuria (thin basement membrane nephropathy)
- Post-infectious glomerulonephritis
- Membranoproliferative glomerulonephritis
- Rapidly progressive glomerulonephritis
- IgA nephropathy
- Systemic lupus erythematosus (SLE)
- Renal cancer
- Metastatic cancer
- Urethral cancer
- Penile cancer
- Placenta percreta
- Bladder stone
- Radiation cystitis
- Nephrotoxic/cytotoxic medications
- Exercise-induced haematuria
- Loin pain haematuria syndrome
Clinical Fellow and Instructor
Division of Urologic Oncology
Memorial Sloan-Kettering Cancer Center
SYK declares that he has no competing interests.
Department of Urology
Santa Clara Valley Medical Center
Clinical Professor of Urology
Stanford University School of Medicine
JHR declares that he has no competing interests.
Associate Professor of Medicine
Division of Nephrology
University of California at San Francisco
LF declares that she has no competing interests.
Assistant Professor of Medicine
University of Illinois
Chicago College of Medicine
Department of Nephrology
MF declares that he has no competing interests.
Consultant Urological Surgeon
Bart's and The London NHS Trust
JM declares that he has no competing interests.
Consultant Urological Surgeon
Homerton University and Bartholomew's Hospitals
VN declares that he has no competing interests.
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