About Blood in the Urine - Hematuria                            by Chin-Ti Lin, M.D.

    Blood in the urine is an important warning to urge patients and professionals to take actions for timely evaluation and counseling so to
    deduce its possible causes and reasonable care. If not, delaying diagnosis may occasionally cost patients' health and life. But, don't
    worry; let me explain to and help you. Read on.

    What is hematuria?
    Hematuria is a medical term to denote blood in urine; "hem- and "-uria" mean blood and urine respectively.
    It has been categorized as follows:  
  • Gross hematuria or macrohematuria or visible hematuria since it is obviously seen by naked eyes;
  • Microhematuria since it is incidentally seen by microscopic exam on the urine for routine workup or specific reasons. A
    discovery of more than 3-5 red blood cells per high power field is considered to be significant, i.e., requiring further investigation
    by reviewing and analyzing detailed history, conducting physical exam, and tests as needed. So

    How to handle blood in the urine?
  1. Seek professional attention as soon as possible - go to see doctors, preferably urologists!
  2. Bring the information on the onset, degree, duration, interval, evolution, and progress of hematuria and its potentially related
    symptoms to the doctor so he/she can analyze them, conduct proper physical exam, and order additional tests timely.

    Why do medical professionals make a big fuss out of microhematuria even though many patients may be
    bothered or disturbed by an emotional turmoil?
    Simply speaking, medical professionals do not want to leave the malignancy - cancer undiagnosed if any possible.

    How possible would the patients with microhematuria be found to have a cancer inside their urinary tract?
    In general, about less than 5% of patients will be found to have a cancer. In other words, you would be correct to say you have no cancer
    in more than 95% of times even though not having any professional training. Since cancers may eventually kill the patients if left
    undiagnosed, medical professionals insist on pursuing thorough evaluation, counseling, and follow-up on microhematuria.

    What are the common causes of microhematuria?
    A review on microhematuria from comprehensive textbooks and available literatures will reveal a long list of more than100 clinical
    conditions which may cause microhematuria. Common examples include, not limited to:
  1. by urinary tract infection (UTI) - bacterial or viral, or STD-related urethritis,
  2. by inflammation - after radiation or chemotherapy, after surgery of bladder, prostate, ureters, kidneys;
  3. by trauma / injury - catheterization, instrumentation such as urethral dilation, surgery, motor accident, vigorous exercise, etc.;
  4. by urinary stones in bladder, ureters, kidneys;
  5. by new growth -  benign or malignant;
  6. by obstruction of urinary tracts at any levels - urethral stricture, prostate enlargement, ureteral obstruction by stone or tumor, etc.;
  7. by renal parenchymal diseases - glomerulonephritis, pyelonephritis, etc. induced by streptococcal infection, antibiotics, ... etc.

    What are the common causes for gross hematuria?
    Largely, all the causes for microhematuria may manifest as gross hematuria. Among those, stones and tumors are most common, and
    anyone with total painless gross hematuria should alert patients, especially in the elderly and smokers, and professionals to look for
    bladder cancer; never delay.

    How should you prepare yourself to see doctors for better effective medical care?
    Before going to see doctors, always collect and bring the detailed information on the onset, degree, duration, interval, evolution, and
    progress of hematuria - micro- or gross, and its potential related symptoms such as pain and difficulty in peeing over time to doctor for
    analysis + physical exam + tests as needed so to deduce most possible diagnosis for most reasonable care for best possible outcome
    from medical care.

    What tests and procedures may you need to define diagnosis and provide treatment?
    1. Tests:
  • urinalysis, urine culture,
  • coagulation profile,
  • kidney functional profile, etc.
  • imaging studies: x-ray - KUB* / IVP*; ultrasound for bladder and kidneys; CT.IVP*, MRI
                    * KUB* stands for x-ray film of kidneys, ureters, and kidneys; IVP*, for intravenous pyelogram, i.e., x-ray exam with IV injection of contrast;

    2. Procedures - diagnostic & therapeutic:
  • Diagnostic - Cystourethroscopy with or without retrograde pyelogram, biopsy, ureteroscopy, etc.
  • Therapeutic - stone removal, stent placement, tumor removal with electric hot loop or laser.

    Of note, the degree and number of needing tests and performing procedures may greatly vary among doctors due to a wide variation in
    their professional confidence and proficiency despite being qualified with diplomas, licenses, and certificates.

    Can doctors always tell you for sure exactly where the blood may come from even after thorough
    evaluation?
    No, most of times, the cause for microhematuria is evident and sure, but doctors still cannot tell you every time exactly what may cause
    microhematuria because it is hard to prove at times and may be multi-factorial.  

    How will you be followed after initial evaluation if nothing important is found?
    If the results of all tests and procedures turn out to have nothing clinically significant / important, it's reasonable to stop here and do
    nothing further for now, but just check urinalysis once every 4-6 months and repeat imaging study and cystoscopy once in 1-2 years.
    Such practice is based on the assumption that a tumor may be just too small to be detected by all means and it may grow in size over
    time, especially for those of high risks - the elderly, the smoker, etc.

    Note, any occurrence of gross hematuria after finding nothing significant in thorough investigation for microhematuria should warn
    patients and doctors to repeat thorough evaluation as described above.  

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    Summary:
    - Reported in 2016 AUA convention in San Diego from NW University in Chicago.

    - Estimated incidence of microhematuria is about 2-30%; higher rate in older people & smokers.

    - Defined as =/> 3 rbc.

    - Cohorts of 11,902 patients from 2008-2011 with 71% females, 48% Caucasian, 22% AA, 4% Hispanic, 3% Asian, and 22%
      unknown; a median of 5.8 years of follow-up for diagnosis of bladder cancer, kidney cancer, and urolithiasis.

    - 61% have 3-10 rbc /hpf at initial urinalysis, and 35.2% had at least one more urinalysis in the 6 months after initial diagnosis.

    - The rates of diagnosis, i.e., the odd to have diagnosis: 4.7% for bladder cancer, 3.1% for kidney cancer, and 16.5% for urolithiasis.

    - If >100rbc/hpf on the first urinalysis is linked to higher rate of these conditions – bladder cancer, kidney cancer, and urinary stone;
      and men and older patients are at the highest risk of malignant diagnoses.

    - Bladder cancer linked to risk of second primary cancer.

    - Standard of workups: imaging studies (CT of abdomen/pelvis with & without contrast or ultrasound) + cystoscopy  with or without
      accessory retrograde pyelogram, ureteroenphroscopy
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