Macroscopic haematuria (non-trauma)

Macroscopic haematuria (visible/gross haematuria) refers to blood clearly visible in urine, unlike microscopic haematuria which is detected only via dipstick.

  • Most critical concern: underlying malignancy (especially in patients >40 years).
  • Most common immediate complication: clot retention.
  • Always consider recent but unrecognised trauma, particularly in non-verbal patients.

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.


References

FOAMed

Publications

Fellowship Notes

Physician in training. German translator and lover of medical history.

Dr James Hayes LITFL author

Educator, magister, munus exemplar, dicata in agro subitis medicina et discrimine cura | FFS |

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