Visible (gross) hematuria is urine that is visibly discolored 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 color to 1 liter of urine.
Visible hematuria, even when transient or asymptomatic, may indicate a significant disease process and always requires further investigation. Possible etiologies vary by age and the workup of visible hematuria differs among children, adults under the age of 35 years, and adults ages 35 years or older.
Patients with visible hematuria represent a higher-risk group for urologic malignancy than those presenting with nonvisible hematuria. Visible hematuria is a presenting sign in more than 66% of patients with urologic cancer. The sensitivity of visible hematuria 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. In men ages >60 years, the positive predictive value of visible hematuria for urologic 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 anemia
- Cystic renal disease
- Arteriovenous malformation
- Renal vein thrombosis
- Alport syndrome
- Extrapulmonary tuberculosis
- Benign familial hematuria (thin basement membrane nephropathy)
- Postinfectious 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 hematuria
- Loin pain hematuria syndrome
Simon Y. Kimm, MD
Clinical Fellow and Instructor
Division of Urologic Oncology
Memorial Sloan-Kettering Cancer Center
SYK declares that he has no competing interests.
Jeffrey H. Reese, MD
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.
Lynda Frassetto, MD
Associate Professor of Medicine
Division of Nephrology
University of California at San Francisco
LF declares that she has no competing interests.
Michael Fischer, MD
Assistant Professor of Medicine
University of Illinois
Chicago College of Medicine
Department of Nephrology
MF declares that he has no competing interests.
Junaid Masood, MBBS, FRCS (Eng), MSc (Urol), FRCS (Urol)
Consultant Urological Surgeon
Bart's and The London NHS Trust
JM declares that he has no competing interests.
Vinod Nargund, PhD, FRCS (Urol), FEBU
Consultant Urological Surgeon
Homerton University and Bartholomew's Hospitals
VN declares that he has no competing interests.
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