Macroscopic haematuria (non-trauma)

Pathophysiology

Causes of non-traumatic macroscopic haematuria:

1. Malignancy: renal, ureteric, or bladder.
2. Benign tumours: e.g. polyps.
3. Infection (UTI): most common cause.
4. Coagulopathy: warfarin, NOACs, or bleeding disorders.
5. Renal tract stones: usually minor haematuria.
6. Acute glomerulonephritis: “cola-coloured” urine (nephrogenic cause).

Differential Diagnosis

Non-RBC causes of red/brown urine:

• Menstruation (spurious)
• Myoglobinuria (e.g. rhabdomyolysis)
• Haemoglobinuria (haemolysis)
• Bilirubinuria
• Dietary (e.g. beetroot)
• Drugs (e.g. rifampicin, doxorubicin)
• Unrecognized trauma

Clinical Assessment

History:

• Recent trauma
• Bleeding disorders/co-morbidities
• Medication (anticoagulants, discolouring agents)
• Dietary factors (e.g. beetroot)

Examination:

• Vital signs: fever, hypertension
• Signs of anaemia or blood loss
• Abdominal exam: renal mass or bladder distension

Investigations

Blood Tests:

• FBE (esp. Hb)
• Glucose
• U&Es/eGFR – Renal impairment, is suggestive of intrinsic renal disease
• PSA (in males)
• Coagulation profile (if indicated)

Urine Tests:

• MSU: microscopy, culture & sensitivity
• Microscopy: casts (GN)
• Cytology: for malignancy

Imaging:

• Renal Ultrasound: best initial screen
• MDCT Urography: detects renal masses, urothelial pathology – This protocol consists of a dedicated contrast Renal Tumour protocol to assess the kidneys followed by a CT-IVP protocol to assess the ureters and bladder.  
• Cystoscopy: gold standard for bladder mucosal evaluation

Management

1. Resuscitation: Fluids or transfusion as needed (rarely necessary)
2. Clot Retention: Insert 3-way catheter + bladder washout
3. Anticoagulant-related bleeding: Evaluate for underlying cause; medication does not exclude pathology

Disposition

• Outpatient follow-up acceptable if stable and malignancy excluded.
• Admit if:
  • Frank haematuria with clot retention
  • Patient is unwell or has concerning test results
  • Significant comorbidities or social concerns

Note: Always involve Urology early for review, particularly in patients >40 or with risk factors for malignancy.

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References

FOAMed

• Parvathy Suresh Kochath. CT Case 090. LITFL
• Rippey J. Ultrasound Case 027. LITFL
• Nickson C. Haematuria in trauma. LITFL

Publications

• Hicks D, Li CY. Management of macroscopic haematuria in the emergency department. Emerg Med J. 2007 Jun;24(6):385-90
• Yeoh M, Lai NK, Anderson D, Appadurai V. Macroscopic haematuria–a urological approach. Aust Fam Physician. 2013 Mar;42(3):123-6.