Haematuria

This guideline applies to adults aged 16yr and older.

Scope: Unexplained haematuria, including urological and renal causes

Out of scope: UTI / pyelonephritis

Renal colic

Gynaecological malignancies

Transient causes of haematuria i.e. menstruation, trauma, instrumentation, exercise-induced haematuria, myoglobinuria

Introduction

Visible haematuria is blood seen within the urine. Non-visible haematuria (NVH) is blood identified on urine dipstick or MSU that is not visible to the naked eye. NVH is defined as 3 or more RBC per High Powered Field (HPF) on a single MSU, often prompted by 1+ BLD or more on urinalysis⁵ (trace BLD can be ignored).

The risk of urothelial malignancy is greater with visible haematuria ~20%, compared to non-visible ~3%¹.

In the context of visible haematuria, or NVH without proteinuria, urological assessment is usually required in the first instance to rule out urothelial causes.

In the context of NVH and proteinuria, a renal assessment is often required first to rule out medical/renal causes.

Red flag features

Aged 45 and over, and have:
- Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
Aged 60 and over, and have:
- Unexplained non-visible haematuria, persistent for more than 2 weeks, and either dysuria or a raised white cell count on a blood test³.

Risk factors for urothelial malignancy include²:

Male sex (almost 3-fold greater risk for bladder cancer)
Increasing age
Smoking (past or current)
Pelvic irradiation
Exposure to cyclophosphamide or other carcinogenic alkylating agents
Exposure to occupational hazards such as dyes, benzenes and aromatic amines

Investigations required prior to referral

Concurrent anticoagulant or antiplatelet use does not exclude patients from undergoing haematuria investigation^2,3. Investigations should not be delayed for a trial off anticoagulation or antiplatelet therapy. Consider a trial of withholding anticoagulation if needed and safe to do so whilst investigating.

Consider:

Blood pressure
Urinalysis*
MSU**
FBC, U&Es, CRP, Ferritin (for renal referrals)
FBC, U&Es (for urology referrals)
PSA for all men aged 50-75 (with visible and NVH)
Urgent Renal tract ultrasound– request at time of referral for cystoscopy. Do not routinely perform CT urography if USS is normal.

*/**If 1+ BLD or more is identified on urinalysis proceed to testing MSU looking for the presence of 3 or more RBC per HPF to confirm the diagnosis of NVH. If a transient/benign cause is suspected, repeat the test after the cause is excluded/treated.

* Urinalysis is not sufficient for the diagnosis of proteinuria; any evidence of proteinuria on dipstick (including trace PRO) should be followed by an ACR to confirm. However, if 2+ or more PRO on urinalysis, a UPCR should be done instead of ACR, as ACR is less precise and useful in cases of significant proteinuria.

Advice and guidance

In absence of red flag features, consider seeking:

Urology Advice and Guidance, for example, if diagnostic uncertainty or ongoing/recurrent visible haematuria which has been previously investigated.
Renal Advice and Guidance, if a urological cause has been excluded.

Referral

Fast Track Suspected Cancer Pathway – Bladder and Renal:

Refer via the Fast Track Suspected Urology Cancer Pathway if:

Aged 45 and over, and have:

Visible haematuria that persists or recurs after successful treatment of urinary tract infection.

Aged 60 and over, and have:

Unexplained non-visible haematuria, persistent for more than 2 weeks, and either dysuria or a raised white cell count on a blood test³.

Imaging suspicious of bladder or renal cancer

Minimum required information:

eGFR within last 6 weeks
any reasonable adjustments required

Urgent Cystoscopy (via eRS):

Request urgent cystoscopy for visible haematuria that does not fulfil the suspected cancer criteria (above).
Request routine cystoscopy for non-visible haematuria that does not fulfil the suspected cancer criteria (above).

Request renal tract ultrasound at time of referral for cystoscopy.

Renal Referral (haematuria and proteinuria):

Patients under 40 years with non-visible haematuria and proteinuria, i.e. suspected medical renal disease, should have albumin/creatinine ratio (or protein:creatinine ratio if protein 2+ or more) measured and initially be referred to a renal physician as per CKD guidelines. If no obvious renal cause is identified, THEN refer to urology for a cystoscopy.
Patients above 40 years with non-visible haematuria AND proteinuria will require a simultaneous referral to both the urology (refer via fast track if meets criteria) and the renal teams.
20% of patients with renal cancer, and some patients with bladder cancer, will have proteinuria⁶, while other patients with non-visible haematuria and proteinuria will have an underlying ANCA-positive renal vasculitis with high risk of rapid deterioration in the renal function.

Recurrent haematuria:

If no cause for non-visible haematuria is found, patients will be discharged from secondary care follow up. Previously investigated recurrent haematuria management is contentious. Previously investigated ongoing/recurrent:

· Visible haematuria– may need repeat investigation. Advice and Guidance discussion or re-referral to urology is advised according to duration/severity or new urologic symptoms

· Non-visible haematuria– need not be re-referred unless clinical concern. Once urological concerns have been ruled out, consider annual urinalysis for haematuria, with ACR for proteinuria if present on dipstick.

· Non-visible haematuria- that becomes visible haematuria, in the absence of urinary tract infection requires referral to urology. Please follow the visible haematuria guidelines above.

Supporting information and references

For professionals

References

Page Review Information

Review date	23 May 2025
Next review date	23 May 2027
GP speciality lead	Dr Laura Vines
Contributors	Miss Elizabeth Bright, Consultant Urologist RCHT Dr Giorgio Gentile, Consultant Nephrologist Dr Melanie Schick, RMS GP Renal Lead