How is hematuria diagnosed?
Visible hematuria is often worrisome to the patient and prompts them to seek medical attention; however, microscopic hematuria can be just as severe. It often has no symptoms and is detected on a urine dipstick test. If the dipstick test is positive for blood the amount of blood is often determined by looking at the urine with a microscope. If three or more red blood cells (RBC) are seen per high power field on two of three specimens, further evaluation to determine a cause is recommended.

What additional tests are needed?
Any patient with gross hematuria or significant microscopic hematuria should have further evaluation of the urinary tract. The first step is a careful history and physical examination. Laboratory analysis consists of a urinalysis and examination of urinary sediment under a microscope. The urine should be evaluated for protein (a sign of kidney disease) and evidence of urinary tract infection. The number of red blood cells per high-powered field should be determined. In addition the shape of the blood cells should be evaluated. This can help determine where the bleeding is coming from. In patients with white blood cells in the urine, a urine culture should be performed as well. A urinary cytology is also obtained to look for abnormal cells in the urine. A blood test should also be done to measure serum creatinine (a measure of kidney function). Those patients with significant protein in their urine, abnormally shaped red blood cells, or an elevated creatinine level should undergo general medical evaluation for the presence of kidney disease.

A complete urologic evaluation for hematuria also includes X-rays of the kidneys and ureters to detect kidney masses, tumors of the ureters and the presence of urinary stones. This traditionally consisted of an intravenous pyelogram (IVP). In this study, a radiographic dye is injected into the blood stream and X-rays are taken as the kidneys excrete the dye. This study has trouble detecting small renal masses and is often combined with a renal ultrasound.

Many physicians may opt for other imaging studies such as a computerized tomography (CT) scan. This is the preferred method of evaluating kidney masses and is the best modality for the evaluation of urinary stones. Recently many urologists have been using CT urography. This allows the urologist to look at the kidneys and ureters with one X-ray test. In patients with an elevated creatinine or an allergy to X-ray dye, magnetic resonance imaging (MRI) or retrograde pyelography is used to evaluate the upper urinary tract. During retrograde pyelography, the patient is taken to the operating room and dye is injected up the ureters from the bladder and then images are taken.

The main limitation of these imaging studies is the inability to evaluate the bladder; therefore a cystoscopic evaluation is required. This is usually performed in the office under local anesthesia with either a rigid, or more commonly, a flexible cystoscope. After applying a topical analgesic to the urethra the urologist inserts an instrument called a cystoscope through the urethra and into the bladder. Looking through the cystoscope the doctor can examine the inner lining of the bladder and urethra for abnormalities.

What happens if no abnormality is found?
In at least eight to 10 percent of cases no cause for hematuria is found. Some studies have demonstrated an even higher percentage of patients have no cause. Unfortunately, studies have shown that urologic malignancy is later discovered in one to three percent of patients with negative work-ups. Therefore, some form of follow-up is recommended. Recommendations regarding follow-up are sparse and no clear consensus has been agreed upon. Consideration should be given to repeating the urinalysis and urine cytology at six, 12, 24 and 36 months. Immediate re-evaluation with possible cystoscopy and repeat imaging should be performed in the face of gross hematuria, abnormal urinary cytology or irritating urinary symptoms such as pain with urination or increased frequency of urination. If none of these symptoms occur within three years, no further urologic testing is needed.

How will hematuria be treated?
Treatment will be based on a physician's evaluation of the patient's condition, symptoms and medical history along with the cause of the hematuria.

Frequently Asked Questions

Where can I get more information?

AUA Foundation Patient Brochure on Hematuria.

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Reviewed February, 2005

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Glossary Terms

abnormality:
	A variation from a normal structure or function of the body.
analgesic:
	A drug intended to alleviate pain.
anesthesia:
	Loss of sensation in any part of the body induced by a numbing or paralyzing agent. Often used during surgery to put a person to sleep.
bladder:
	The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.
cancer:
	An abnormal growth that can invade nearby structures and spread to other parts of the body and may be a threat to life.
computerized tomography:
	Also known as computerized tomography, computerized axial tomography or CT scan. A diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce cross-sectional images of the body. Shows detailed images of any part of the body, including bones, muscles, fat and organs. CT scans are more detailed than general X-rays.
creatinine:
	A waste product from meat protein in the diet and from the muscles of the body. Creatinine is removed from blood by the kidneys; as kidney disease progresses, the level of creatine in the blood increases.
culture:
	Biological material grown under special conditions.
cyst:
	An abnormal sac containing gas, fluid or a semisolid material. Cysts may form in kidneys or other parts of the body.
cystoscope:
	A narrow, tube-like instrument fitted with lenses and a light passed through the urethra to look inside the bladder. The procedure is called cystoscopy (sis-TAW-skuh-pee).
cystoscopic:
	Viewing the bladder with a narrow, tube-like instrument passed through the urethra.
cystoscopy:
	Also known as cystourethroscopy. An examination with a narrow, flexible tube-like instrument passed through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones.
cytology:
	The examination of cells obtained from the body tissue or fluids, especially to establish if they are cancerous.
dipstick test:
	A measuring rod is dipped into a container to test urine for chemicals that suggest whether blood might be present and whether white blood cells might be present. This test can also show the pH (acidity) of your urine and how concentrated your urine is.
excrete:
	Expel liquid and solid waste from the body.
frequency:
	The need to urinate more often than is normal.
gene:
	The basic unit capable of transmitting characteristics from one generation to the next.
hematuria:
	Blood in the urine, which can be a sign of a kidney stone or other urinary problem. Gross hematuria is blood that is visible to the naked eye. Microscopic hematuria cannot be seen but is detected on a urine test.
infection:
	A condition resulting from the presence of bacteria or other microorganisms.
intravenous:
	Also referred to as IV. Existing or occurring inside a vein.
intravenous pyelogram:
	Also referred to as IVP, intravenous urography or excretory urogram. An X-ray of the urinary tract. A dye is injected to make urine visible on the X-ray and show any blockage in the urinary tract.
ions:
	Electrically charged atoms.
IV:
	Also referred to as intravenous. Existing or occurring inside a vein.
IVP:
	Also referred to as intravenous pyelogram, intravenous urography or excretory urogram. An X-ray of the urinary tract. A dye is injected to make urine visible on the X-ray and show any blockage in the urinary tract.
kidney:
	One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.
kidneys:
	One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.
local anesthesia:
	Loss of sensation only in one part of the body induced by application of an anesthetic agent.
magnetic resonance imaging:
	Also referred to a MRI. A diagnostic procedure that uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body.
malignancy:
	A cancerous growth.
MRI:
	Also referred to a magnetic resonance imaging. A diagnostic procedure that uses a combination of large magnets, radiofrequencies and a computer to produce detailed images of organs and structures within the body.
nephritis:
	Inflammation of the kidneys.
prostate:
	A walnut-shaped gland in men that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.
radiation:
	Also referred to as radiotherapy. X-rays or radioactive substances used in treatment of cancer.
radiographic:
	X-ray.
renal:
	Pertaining to the kidneys.
renal ultrasound:
	A non-invasive test in which a transducer is passed over the kidney producing sound waves that bounce off the kidney, transmitting a picture of the kidney on a video screen. The test is used to detect any abnormalities.
retrograde:
	Backwards.
retrograde pyelography:
	Radiographic imaging of the ureters and collecting system of the kidneys by introducing a dye opaque to X-rays by way of urinary catheter.
serum:
	Clear, watery body fluid.
serum creatinine:
	Important reserve of energy for muscle contractions.
stone:
	Small hard mass of mineral material formed in an organ.
stone disease:
	An abnormal concretion of mineral salts around organic material found especially in hollow organs or ducts.
topical:
	Describes medication applied directly to the surface of the part of the body being treated.
topical analgesic:
	A drug applied directly to the surface of the body to alleviate pain.
tumor:
	An abnormal mass of tissue or growth of cells.
ultrasound:
	Also referred to as a sonogram. A technique that bounces painless sound waves off organs to create an image of their structure to detect abnormalities.
ureter:
	One of two tubes that carry urine from the kidneys to the bladder.
ureters:
	Tubes that carry urine from the kidneys to the bladder.
urethra:
	A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.
urinal:
	A portable device that is used as a receptacle for urine.
urinalysis:
	A test of a urine sample that can reveal many problems of the urinary system and other body systems. The sample may be observed for physical characteristics, chemistry, the presence of drugs or germs or other signs of disease.
urinary:
	Relating to urine.
urinary cytology:
	Inspection under a microscope of cells found in the urine.
urinary tract:
	The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.
urinary tract infection:
	Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.
urination:
	The passing of urine.
urine:
	Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.
urine culture:
	Sample of urine for diagnostic purposes.
urologist:
	A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)

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