Assessment of visible haematuria

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 L of urine.

Visible haematuria, even when transient or asymptomatic, may indicate a significant disease process and always requires further investigation. Possible aetiologies vary by age and the work-up of visible haematuria differs among 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.[1]Nielsen M, Qaseem A. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016 Apr 5;164(7):488-97. https://annals.org/aim/fullarticle/2484287/hematuria-marker-occult-urinary-tract-cancer-advice-high-value-care http://www.ncbi.nlm.nih.gov/pubmed/26810935?tool=bestpractice.com [2]Kaag MG, Raman JD. Clinical guidelines: Clearing murky water - a guideline-based approach to haematuria. Nat Rev Urol. 2016 Apr 13;13(5):243-4. http://www.ncbi.nlm.nih.gov/pubmed/27071454?tool=bestpractice.com [3]Loo RK, Lieberman SF, Slezak JM, et al. Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria. Mayo Clin Proc. 2013 Jan 9;88(2):129-38. http://www.ncbi.nlm.nih.gov/pubmed/23312369?tool=bestpractice.com Visible haematuria is a presenting sign in more than 66% of patients with urological cancer.[4]Edwards TJ, Dickinson AJ, Natale S, et al. A prospective analysis of the diagnostic yield resulting from 4020 patients at a protocol-driven haematuria clinic. BJU Int. 2006 Feb;97(2):301-5. http://www.ncbi.nlm.nih.gov/pubmed/16430634?tool=bestpractice.com 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.[5]Buntinx F, Wauters H. The diagnostic value of macroscopic haematuria in diagnosing urological cancers: a meta-analysis. Fam Pract. 1997 Feb;14(1):63-8. https://academic.oup.com/fampra/article/14/1/63/548718 http://www.ncbi.nlm.nih.gov/pubmed/9061347?tool=bestpractice.com 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%.[6]Hicks D, Li CY. Management of macroscopic haematuria in the emergency department. Postgrad Med J. 2008 Oct;84(996):539-44. http://www.ncbi.nlm.nih.gov/pubmed/19017839?tool=bestpractice.com

Risk factors for urothelial carcinoma include:

• Male sex

• Age 35 years or older

• Smoking

• 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

  • Pelvic irradiation.