Blood in the urine, an overview of haematuria
The presence of blood in urinary fluids is referred to in medical parlance as haematuria. It is a condition that can occur in different stages of severity and can be caused by bleeding from any component of the urinary tract (kidneys, ureters, bladder or urethra)
When one of these organs is subjected to infection or trauma, blood loss may occur and be detected in the urine.
There are cases in which haematuria is easily recognisable as the urine turns a deep red or brown colour, causing concern in the affected patient.
Other times, haematuria is mild and not visible to the naked eye
Blood loss is minimal and the presence of the condition is only detectable following appropriate investigations.
Although mild haematuria is usually transient and does not necessarily indicate a more serious medical condition, it should be remembered that, under physiological conditions, blood should not be present in the urine.
Therefore, whenever you notice a sudden change in the colour of your kidney excretions or difficulty urinating, you should visit your doctor as soon as possible.
Blood in the urine can in fact be an alarm bell for the presence of more serious illnesses affecting the organism, which can lead to the presence of blood in the urine as a symptom.
Haematuria, when blood in the urine occurs
Haematuria may occur sporadically or become recurrent.
If it appears as an isolated case it should not cause particular concern, although it is still necessary to seek a consultation with your doctor who, following an appropriate objective test, will be able to establish the cause.
If, on the other hand, the presence of blood in the urine is frequent and the amount of blood lost is copious, it means that the situation is worthy of more thorough diagnostic tests that rule out the presence of the results of a severe trauma or ongoing inflammation.
Following an in-depth meta-analysis of haematuria, experts noted that, depending on when the blood occurs during the act of urination, one can speculate which urinary organ is responsible for the bleeding.
If the bleeding is at the beginning of urination, it is called initial haematuria, usually associated with prostate or urethral disease.
When bleeding continues throughout urination, the problem may affect the bladder, ureter or kidneys (i.e. the entire urinary system).
Finally, if you notice a loss of blood in the final phase of the act, it means that it is probably the bladder that is affected by the problem.
In general, the colour of the urine (pink, red, brown) varies depending on the amount of blood present, the duration of stagnation of the urine and its acidity level.
Haematuria, all classifications
Urologists have drawn up a classification of haematuria based on the colouring of the urine following blood loss and the amount of blood found in it.
Classification of haematuria according to urine colouring
We speak of frank haematuria when the urine takes on a bright red colour like that of blood.
It indicates that there is significant bleeding in progress.
Flesh-washing haematuria occurs when the urine is pinkish in colour, suggesting mild bleeding.
If the urine is brown in colour, it means that it contains ‘old’ and clotted blood.
Bleeding has already occurred or the leakage results from haemoglobinuria.
The same colouring is assumed by urine fluids in all those cases where leakage occurs due to small expelled clots.
Classification of haematuria according to the amount of blood in the urine
A situation of macrohaematuria means that the level of blood in the urine is so high that it is visible to the naked eye, changing its colour to red.
If the urinary pH is very acidic, the colour is more likely to be dark brown.
The same happens when urination is delayed and urine stagnates for a long time in the urinary tract.
We are dealing with microhaematuria when the amount of blood excreted with the urine is minimal and the presence of haematuria can only be detected by urine culture.
False haematuria
The diagnosis of haematuria is mistakenly associated with all cases in which one notices a change in one’s urine fluid.
However, there are examples in which, even if the urine changes colour to pink/red, it cannot be described as haematuria:
- Menstruation: a common situation for all women of childbearing age. Vaginal bleeding, which joins with urine, comes from the shedding of the uterine mucosa after the menstrual cycle. These losses end with the end of menstruation. The same can occur in the presence of endometriosis.
- Intake of certain foods in quantities beyond normal (beets, blueberries, rhubarb, food colouring).
- Intake of certain drugs that, due to the presence of particular active ingredients, can colour the urine red (cascara laxatives, phenacetin, phenytoin, ibuprofen, methyldopa, rifampicin).
- Myoglobinuria: myoglobin is a muscle protein that is excreted following muscle damage and that, when it reaches the kidney, passes through the glomerulus and spills into the urine, giving it a dark red colour.
- Haemoglobinuria: presence in the urine of haemoglobin, the blood protein responsible for transporting oxygen and carbon dioxide.
In these dubious conditions, it is essential to prescribe and perform a thorough urine test to rule out false diagnoses of haematuria.
Haematuria, the symptoms
In many cases, making an early diagnosis of haematuria is not possible because it presents as totally asymptomatic.
However, there are common symptoms felt in the urinary tract that, even in the absence of macroscopic haematuria, act as a sign of the possible presence of pathological changes.
If you experience even one of these symptoms, you should visit your doctor for an examination because, as already mentioned, finding blood in the urine or having problems with urination are abnormal situations for a healthy individual.
Here is a non-exhaustive list of symptoms associated with haematuria.
Others may be added, depending on the specific pathology present:
- irritation of the kidneys, urethra, bladder or prostate,
- difficult urination and urine colouring that differs from normal,
- continuous feeling of urinary need,
- fever, chills, burning in the lower abdomen, as well as difficulty urinating (a symptom of an ongoing urinary tract infection),
- kidney stones with pain in the abdominal, lumbar, groin and genital area.
Haematuria, the causes
Generally, haematuria is associated with benign and treatable conditions such as infections of the genitourinary system.
Rare are the cases in which haematuria is a symptom of the presence of more serious dysfunctions, such as tumours or disorders of vital organs.
The most common diseases and conditions that can lead to the presence of blood in the urine are:
- cystitis: inflammation of the bladder wall can lead to blood loss,
- prostatitis, benign prostatic hyperplasia, prostate cancer,
- kidney, ureteral or bladder stones,
- kidney diseases: there are various diseases that manifest themselves as nephritis that can lead to blood in the urine,
- kidney or urinary tract trauma: as a result of trauma, clots may form and obstruct the urinary flow. In these cases, there are twinges and difficulty in urination, with bleeding at the act,
- ruptured cysts (especially in polycystic kidney),
- renal, urethral, bladder or genital tumours,
- Wilson’s disease,
- taking certain medications (anti-inflammatory NSAIDs, acetylsalicylic acid, warfarin, clopidogrel, anticoagulants)
- prolonged and repeated exercise,
- platelet dysfunction and coagulation disorders,
- sexually transmitted diseases (generally chlamydia and gonorrhoea).
It should be borne in mind that gender and age may be a risk factor for the development of these diseases.
Diagnosis: how to measure blood in the urine
The presence of blood in the urine is never a symptom to be underestimated.
As soon as you become aware of its presence, you should notify your general practitioner who will carry out a thorough clinical and anamnestic test.
During the examination, the doctor investigates the patient’s medical history and collects information on current and previous symptoms.
The tests that are prescribed in the first instance generally include a urine test with urinoculture, an antibiogram and an evaluation of the urine sediment, which is useful for obtaining information on the health of the renal glomerulus.
Urine collection for the diagnostic test must be performed in the morning, on an empty stomach (as with a normal blood test), in a disposable, sterile container.
Evaluation is done by observing the urine drops directly under a microscope.
This technique is often used when the amount of blood in the urine is minimal and not directly visible to the naked eye.
The purpose of this analysis is to
- assess the type of haematuria, the amount of blood in the urine, its colour, when the bleeding occurs.
- assess whether there are any associated problems: whether the blood in the urine is a symptom of previous trauma, neoplastic disease or infection.
When an objective test is not enough, the general practitioner may decide to prescribe a specialist urological examination and other diagnostic investigations.
Blood tests are often prescribed together with urine culture, as they make the diagnostic process easier, especially if alterations in the coagulation system are detected.
A complete ultrasound of the genitourinary system is useful to observe the extent of damage after trauma, the presence of kidney stones, malformations or expansive processes in the urinary tract.
Level 2 diagnostic tests include urography, urotac, abdominopelvic CT scan and urethrocystoscopy.
Observation of symptoms and a careful objective test are always essential as they allow the doctor to rule out the presence of certain pathologies.
Blood in the urine, treatments
There is no specific and unambiguous treatment for haematuria as it is not a disease as such, but rather a symptom of the presence of other organic pathologies.
For this reason, treatment varies depending on the underlying pathology found.
If haematuria is caused by an infection, it is up to the urologist or one’s GP to prescribe an appropriate antibiotic therapy.
Following a specific test called an antibiogram, the most effective therapy in that specific case is identified.
If haematuria is caused by the presence of kidney stones, it is recommended to drink a lot in order to eliminate the concretions, or to break them up using lasers, shock waves or other techniques.
If haematuria is induced by prostatic hypertrophy, appropriate drug therapy must be followed.
If the hypertrophy is severe, it is likely that minimally invasive endoscopic removal of the enlarged portion of the prostate will be required.
Finally, if there are blood clots present that interrupt the flow of urine, the doctor may decide to insert a special flexible tube called a urinary catheter into the bladder to directly remove the cause of obstruction, resolving the urination problem.
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