Investigation of haematuria

Preliminary investigations may be undertaken in primary care once transient causes of haematuria are excluded (1). These include:

• urinalysis:
  • dipstick testing
    • to exclude other causes of a red urine
    • dipstick urinalysis for blood is indicated as part of the initial assessment of patients with
      • newly detected GFR < 60 ml/min/1.73 m2
      • newly discovered proteinuria
      • suspected multisystem disease with possible renal involvement (2)
  • mid stream urine for:
    • microscopy
      • the presence of red cells excludes haemoglobinuria
      • presence of more than two red cells per high-power field on microscopy is abnormal (although the cut off point varies between ≥2 cells per high power field and≥5 cells per high power field) and requires further investigation
      • other findings may suggest infection or renal disease
    • culture and sensitivity - guides antibiotic selection if due to infection
  • 24-hour urine creatine clearance and urinary protein excretion - this is used to detect mild degrees of renal impairment
• blood tests:
• urea and electrolytes - to assess renal impairment
• full blood count - may require transfusion
• clotting - especially if taking anticoagulants
• imaging investigations include:
  • plain film of kidney, ureters and bladder
  • intravenous urography
  • ultrasound scan - instead of, or in addition to, IVU

Further investigations may include:

• cystoscopy
• imaging
  • intravenous urography (IVU)/intravenous pylography (IVP)
  • USS
  • CT scan
  • MRI
• renal biopsy - if histological diagnosis is indicated (4)

Note:

• there is no need in routine clinical practice for confirmation of haematuria by microscopy of a midstream urine sample (3)

Reference:

• (1) Kelly JD, Fawcett DP, Goldberg LC. Assessment and management of non-visible haematuria in primary care. BMJ. 2009;338
• (2) Renal Association and British Association of Urological Surgeons (2008). Joint Consensus Statement on the Initial Assessment of Haematuria
• (3) Rees J, Patel B, Persad R. Asymptomatic dipstick haematuria. Trends in Urology Gynaecology & Sexual Health 2008
• (4) Rodgers M et al. Diagnostic tests and algorithms used in the investigation of haematuria: systematic reviews and economic evaluation; Health Technology Assessment 2006;10(18)