Definition

Hematuria is a condition characterized by the presence of blood in the urine. It is considered a significant symptom or sign of an underlying disease. Bleeding can occur in any organ involved in the expulsion of urine, including the kidneys, urethra, bladder, and ureters. The urinary system's primary function is to filter blood and remove waste in the form of urine. In certain diseases, blood may be expelled along with urine. Blood may be visible directly in the urine or detected through laboratory examination. Prompt identification of the cause of hematuria is essential for appropriate treatment.

Causes

Hematuria occurs when red blood cells enter the urine and travel through the kidneys and urinary tract. Bleeding can originate from various parts of the urinary system, including the kidneys, ureters, bladder, and urethra. Several conditions can lead to hematuria, including:

• Urinary tract infection (UTI): Bacterial invasion of the urethra and subsequent migration to the bladder can cause UTIs. In some cases, bleeding may only be detected through laboratory tests.
• Kidney infection (pyelonephritis): Bacteria ascending from the ureter or bloodstream can lead to kidney infections. Symptoms often include fever and back pain.
• Kidney or bladder stones: Crystals formed from certain minerals can accumulate over time, leading to the formation of hard stones. Initially, these stones may not cause pain, but obstruction of urine flow can result in colicky pain and visible or lab-detected hematuria.
• Enlarged prostate gland: Prostate enlargement, commonly seen in older men, can narrow the urethra and obstruct urine flow, leading to hematuria detected during laboratory tests.
• Kidney disease: Glomerulonephritis, characterized by inflammation in the kidney's filtration system, often presents with microscopic hematuria. It can be caused by infections, diabetes, or autoimmune diseases.
• Cancer: Hematuria may indicate kidney, bladder, or prostate cancer.
• Congenital conditions: Blood disorders such as sickle cell anemia and hemophilia, which affect blood clotting, can lead to hematuria due to abnormal blood cell shapes.
• Kidney injury: Trauma to the kidney area, such as accidents or blows, can cause visible hematuria.
• Certain medications: Some drugs, including anticancer drugs, penicillin antibiotics, and anticoagulants like aspirin and heparin, may induce hematuria.
• Intense exercise: Although relatively rare, intense physical activity may cause hematuria in some individuals, though the exact cause is still unclear.

Risk factor

Hematuria can affect individuals of all sexes and ages, and various underlying causes can contribute to its occurrence. However, certain factors can increase the risk, such as:

• Men over 50 years of age: The risk of prostate enlargement increases with age
• History of kidney stones or current treatment for them
• Recent infections: Bacterial or viral infections of the kidneys mainly occur in children
• Family history: A family history of kidney disease
• Certain medications: The use of aspirin, NSAIDs, and penicillin antibiotics
• Intense exercise: For example, marathon runners
• Smoking habits: Increases the risk of cancer

Symptoms

Under normal conditions, urine does not contain blood. Hematuria can be classified into two types:

• Gross hematuria: Signs of gross hematuria include a noticeable change in urine color to pink, red, or cola-colored brown due to a high concentration of red blood cells. While this bleeding typically does not cause pain, discomfort may be experienced during urination.
• Microscopic hematuria: Microscopic hematuria refers to the presence of red blood cells in the urine that can only be detected under a microscope during laboratory examination. No significant changes in urine color or appearance are typically observed.

Hematuria can occur without symptoms, but certain additional symptoms may indicate the underlying cause. Symptoms such as painful urination, cloudy urine, fever, or abdominal and back pain may suggest a urinary tract infection or kidney infection. Conversely, if these symptoms are accompanied by weight loss, decreased appetite over time, and a history of smoking, the likely cause may be cancer.

Diagnosis

The doctor will conduct a medical interview to gather information about the symptoms experienced. Following this, a physical examination will be performed to confirm any anomalies. Additionally, the doctor may conduct the following tests to assess the cause of hematuria and determine appropriate treatment:

• Urine test or urinalysis: This laboratory test is utilized to detect red blood cells under a microscope. It also helps identify urinary tract infections or specific minerals from kidney stones.
• Blood test: Typically performed to assess kidney function.
• Radiological tests: These may include ultrasound (USG), CT scan, or MRI scans. These tests aim to detect abnormalities such as kidney stones, tumors, or other disorders.
• Cystoscopy: This procedure involves using a cystoscope, a small tube with a camera, inserted through the urethra to visualize the inside of the urinary tract. In certain cases, a biopsy or tissue sample may be taken.
• Kidney biopsy: This procedure may be performed if kidney disease or kidney cancer is suspected.

It's important to note that the cause of hematuria may not be identified even after undergoing multiple examinations. Regular check-ups with your doctor are recommended, especially if you have a high risk of cancer.

Management

Treatment for hematuria is determined based on the underlying primary causes. Depending on the specific condition, treatment options may vary. 

For instance, antibiotics are often prescribed to address urinary tract infections (UTIs), which are a common cause of hematuria. In cases of prostate enlargement, medications may be recommended to reduce the size of the prostate, alleviating pressure on the urinary tract. Additionally, shockwave lithotripsy (ESWL) may be utilized to break up kidney or bladder stones, facilitating their passage through the urinary tract. 

If the exact cause of hematuria cannot be determined or effectively treated, the doctor may refer the patient to a urologist for further evaluation and management.

Complications

Complications of hematuria may arise if the underlying cause is not adequately managed, and these complications can vary depending on the specific cause. For instance, untreated infections can progress and result in permanent kidney damage. Similarly, delayed treatment in cases of cancer can exacerbate the condition, leading to further complications.

Prevention

Preventive measures can help mitigate the risk factors associated with various diseases. Here are some preventive measures that can be implemented at home:

• Ensure adequate fluid intake
• Urinate after sexual intercourse.
• Maintain good hygiene practices
• Reduce salt consumption
• Quit smoking
• Avoid excessive use of pain relievers
• Avoid exposure to certain chemicals and radiation
• Avoid strenuous exercise, such as long-distance running for prolonged periods

When to see a doctor?    

Seek medical attention immediately if you notice blood in your urine, as this condition requires prompt and proper treatment. While some causes of red-colored urine, such as certain medications or foods, may resolve within a few days, if the bloody urine persists, it's important to seek medical attention promptly. Be vigilant for danger signs such as a significant amount of blood in the urine, high fever, severe lower abdominal and back pain, as well as nausea and vomiting. If symptoms of hematuria persist despite treatment, consult a doctor for further evaluation and management.

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