Evaluation of visible hematuria

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 L 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 and adults, depending on their risk factors.

Patients with visible hematuria represent a higher-risk group for urologic malignancy than those presenting with nonvisible hematuria.[1]Takeuchi M, McDonald JS, Takahashi N, et al. Cancer prevalence and risk stratification in adults presenting with hematuria: a population-based cohort study. Mayo Clin Proc Innov Qual Outcomes. 2021 Apr;5(2):308-19. https://www.mcpiqojournal.org/article/S2542-4548(20)30253-8/fulltext http://www.ncbi.nlm.nih.gov/pubmed/33997630?tool=bestpractice.com [2]Rai BP, Luis Dominguez Escrig J, Vale L, et al. Systematic review of the incidence of and risk factors for urothelial cancers and renal cell carcinoma among patients with haematuria. Eur Urol. 2022 Aug;82(2):182-92. http://www.ncbi.nlm.nih.gov/pubmed/35393159?tool=bestpractice.com ​​​​ Pooled incidence rates of 17%, 2%, and 0.75% for urothelial bladder cancer, renal cell carcinoma, and upper tract urothelial carcinoma, respectively, have been reported among patients undergoing investigation for visible hematuria.[2]Rai BP, Luis Dominguez Escrig J, Vale L, et al. Systematic review of the incidence of and risk factors for urothelial cancers and renal cell carcinoma among patients with haematuria. Eur Urol. 2022 Aug;82(2):182-92. http://www.ncbi.nlm.nih.gov/pubmed/35393159?tool=bestpractice.com Visible hematuria prevalence may be more than 68% in patients with urologic cancer.[3]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 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.[4]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 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%.​[5]Bruyninckx R, Buntinx F, Aertgeerts B, et al. The diagnostic value of macroscopic haematuria for the diagnosis of urological cancer in general practice. Br J Gen Pract. 2003 Jan;53(486):31-5. https://bjgp.org/content/53/486/31.long http://www.ncbi.nlm.nih.gov/pubmed/12564274?tool=bestpractice.com

Risk factors for urothelial carcinoma include:[2]Rai BP, Luis Dominguez Escrig J, Vale L, et al. Systematic review of the incidence of and risk factors for urothelial cancers and renal cell carcinoma among patients with haematuria. Eur Urol. 2022 Aug;82(2):182-92. http://www.ncbi.nlm.nih.gov/pubmed/35393159?tool=bestpractice.com ​​[6]Lucca I, Klatte T, Fajkovic H, et al. Gender differences in incidence and outcomes of urothelial and kidney cancer. Nat Rev Urol. 2015 Oct;12(10):585-92. http://www.ncbi.nlm.nih.gov/pubmed/26436686?tool=bestpractice.com [7]Jubber I, Ong S, Bukavina L, et al. Epidemiology of bladder cancer in 2023: a systematic review of risk factors. Eur Urol. 2023 Aug;84(2):176-90. https://www.sciencedirect.com/science/article/pii/S0302283823027070 http://www.ncbi.nlm.nih.gov/pubmed/37198015?tool=bestpractice.com [8]Kabaria R, Klaassen Z, Terris MK. Renal cell carcinoma: links and risks. Int J Nephrol Renovasc Dis. 2016;9:45-52. https://www.dovepress.com/renal-cell-carcinoma-links-and-risks-peer-reviewed-fulltext-article-IJNRD http://www.ncbi.nlm.nih.gov/pubmed/27022296?tool=bestpractice.com [9]Dy GW, Gore JL, Forouzanfar MH, et al. Global burden of urologic cancers, 1990-2013. Eur Urol. 2017 Mar;71(3):437-46. http://www.ncbi.nlm.nih.gov/pubmed/28029399?tool=bestpractice.com

• Male sex

• Increasing age

• Smoking

• Obesity

• 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.