Blood in urine

Dr Ajay Anand
Blood in urine referred to as haematuria in clinical practice is an unwelcome ominous sign.There are innumerable causes of haematuria but common urological causes broadly encountered in our clinical practice, in order of frequency, include:-
*Carcinoma of urinary bladder/urothelium
*Benign enlargement of proState (BEP)
*Urinary tract infection
*Urinary calculi
*Renal cell carcinoma
*Radiation cystitis
Haematuria in carcinoma of urinary bladder and BEPare painless, whereas other entities may be associated with painful haematuria.
Urine examination and ultrasonogram are initial baseline investigations to arrive at an initial clue to diagnosis and planning further investigative and treatment protocol, depending upon theetiology.
Haematuria in carcinoma of urinary bladder and BEP are usually associated with clots which are usually amorphous and round in shape, whereas clots are vermiform in shape when source of haematuria is upper tracts, that is kidneys or ureters.
Carcinoma of urinary bladder is four times more common in smokers vis a vis non-smokers; and is more common in males than females. Patients present with painless haematuria and at times with acute urinary retention. There are certain high risk occupations which predispose to carcinoma of urinary bladder. These include persons exposed to pesticides, aniline dye, aromatic hydrocarbons etc. Carcinoma of urinary bladder needs urgent urological intervention and further treatment is guided by findings on biopsy of specimen.
BEP is another cause of painless haematuria seen in elderly male population. Presentation is same as that in carcinoma of urinary bladder. Such patients usually have prior history of lower urinary tract symptoms in form of increased frequency of micturition, weak stream, urgency, straining to void etc. This can be treated either by medical treatment by use of 5 alpha reductase inhibitors – Finasteride or dutasteride. Patients with BEP and haematuria need to be investigated by urologist to exclude other causes of haematuria. Surgical treatment in form of TURP is definitive curative treatment for this disease entity.
Urinary tract infection is a rare cause of gross haematuria unlike above two entities (Carcinoma of urinary bladder and BEP – which may be associated with gross haematuria and urinary retention). UTI can be diagnosed by urine examination-both routine and culture coupled with ultrasonogram of kidney, ureter and bladder to find out any evident cause of UTI. Treatment is straightforward – antibiotics preferably culture and sensitivity guided. Recurrent UTIs need further investigation by urologist and treatment of precipitating factor, if any.
Urinary calculi are almost always associated with pain as predominant symptom, which may be accompanied with haematuria. Proper work-up and definitive surgical treatment depending upon stone size, location and composition, is the only curative option for this group of patients.
Renal cell carcinoma is a rare cause of gross haematuria as presenting symptom.It has different modes of presentation. Usually small RCCs are discovered as an incidental finding on ultrasonogram for some other abdominal complaints. Triad of lump, flankpain and haematuria is seen in only 16 % of patients. Rarely patients present with paraneoplastic syndromes that is symptoms because of metabolites or hormones secreted by tumour, which is seen in 13% of patients. This needs thorough radiologic evaluation to assess size of tumour and to exclude metastasis. Only curative treatment is surgical which may be in form of radical nephrectomy or partial nephrectomy, depending upon size and location of tumour.
Radiation cystitis is another rare cause of gross haematuria which may be associated with clots. This is usually seen in persons who have received pelvic irradiation in past for some pelvic malignancy like carcinoma cervix, adjuvant radiotherapy for gastrointestinal malignancy etc. This is a debilitating condition with no definitve curative treatment. Treatment options used include alum instillation, hyperbaric oxygen therapy and fulgration, which do provide control of haematuria in such group of patients.
(The author is presently working as Consultant Urologist in Superspeciality Hospital, GMC, Jammu).