‘Doctor, I have blood in my urine’

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technician placing blood tubes in the laboratory centrifuge

Dr Alex Danso Consulant Urologist
Doctor, I have seen blood in my urine, but I am not in pain. Is this dangerous?This week we discuss a condition in which there is blood in the urine. This is called Haematuria when observed with the eyes we call it Macrohaematuria or Gross haematuria and when observed only through a microscope, we call it Microhaematuria. When the blood in the urine is associated with pain, it is called painful haematuria and when not associated with pain it is called painless haematuria. Haematuria, especially painful haematuria can cause a lot of anxiety and yet it may be a sign of a harmless disorder whereas painless haematuria which may not cause any anxiety may be a signal for a more serious disorder. Whatever form it takes, haematuria needs further investigation. Symptoms: Normal urine must have NO COLOUR and must not have ODOUR. Hence when urine is found to be red, pink,brown or cola coloured it indicates that there is the presence of red blood cells in the urine. This can occur on its own or with other symptoms and signs. Sometimes the passage of clots may occur and this can be quite painful. The normal urinary tract is made up of the kidneys, the ureters, the bladder and  the urethra (surrounded by the prostate in males). The urinary tract has the distinct integrity as a filter which does not allow any blood cells to filter through. Observing blood in the urine therefore means that blood cells have been able to filter through this “sieve”. Even a small amount of blood can cause the change in colour of  the urine . What causes this leakage of blood through the urinary tract?Urinary tract infections. Urinary tract infections often occur when bacteria enter your body through the urethra and begin to multiply in your bladder. Symptoms can include a persistent urge to urinate, pain and burning with urination, and extremely strong-smelling urine.Kidney infections: Kidney infections (pyelonephritis) can occur when bacteria enter your kidneys from your bloodstream or move up from your ureters to your kidney(s).  Kidney infections are more likely to cause additional fever and flank pain.A bladder or kidney stone: Bladder or kidney stones can cause both gross and microscopic bleeding.Enlarged prostate: Signs and symptoms of an enlarged prostate (benign prostatic hyperplasia, or BPH) include difficulty urinating, an urgent or persistent need to urinate, and either visible or microscopic blood in the urine. Infection of the prostate (prostatitis) can cause the same signs and symptoms.Kidney disease: Microscopic urinary bleeding is a common symptom of glomerulonephritis, which causes inflammation of the kidneys’ filtering system.Glomerulonephritis may be part of a systemic disease, such as diabetes, or it can occur on its own. Cancer: Gross haematuria may be a sign of advanced kidney, bladder or prostate cancer. Unfortunately, you may not have signs or symptoms in the early stages, when these cancers are more treatable.Inherited disorders: Sickle cell anaemia — a hereditary defect of haemoglobin in red blood cells — can be the cause of blood in urine, both visible and microscopic haematuria. Kidney injury: A blow or other injury to your kidneys from an accident or contact sports can cause gross haematuria.Medications: The anti-cancer drug cyclophosphamide (Cytoxan) and penicillin can cause urinary bleeding. Visible urinary blood sometimes occurs if you take an anticoagulant, such as aspirin and the blood thinner heparin.Bilharzia: Bilharzia can cause bleeding in the urinary tract. In Egypt and Zimbabwe this is a prominent cause of the haematuria. Strenuous exercise: Sometimes strenuous exercise may lead to gross hematuria. It may be linked to trauma to the bladder, dehydration or the breakdown of red blood cells that occurs with sustained aerobic exercise. Runners are most often affected, although almost any athlete can develop visible urinary bleeding after an intense workout.Because there is a multitude of causes for the blood in the urine, it is reassuring to get it investigated by your doctor so that sinister causes are detected . Examinations, Investigations and Tests To reach a diagnosis , your doctor may require your medical history, may perform physical examination in addition to urine test and imaging . Medical HistoryTaking a medical history may help a health care professional diagnose the cause of haematuria. He or she will ask the patient to provide a medical history, a review of symptoms, and a list of prescription and over-the-counter medications. The health care professional will also ask about current and past medical conditions.Physical ExamDuring a physical exam, a health care professional most often taps on the abdomen and back, checking for pain or tenderness in the bladder and kidney area.A health care professional may perform a digital rectal exam on a man to look for any prostate problems. A health care professional may perform a pelvic exam on a woman to look for the source of possible red blood cells in the urine.Digital rectal exam: A digital rectal exam is a physical exam of a man’s prostate and rectum. Pelvic exam: A pelvic exam is a visual and physical exam of a woman’s pelvic organs. UrinalysisThe health care professional can test the urine in the office using a dipstick or can send it out to a lab for analysis. Sometimes urine tests using a dipstick can be positive even though the patient has no blood in the urine, which results in a “false-positive”                                                      test. The health care professional may look for red blood cells by examining the urine under a microscope before ordering further tests.The health care professional may confirm the presence of red blood cells by examining the urine under a microscope before ordering further tests.Additional TestingSometimes, a health care professional will test the patient’s urine again. If the urine samples detect too many red blood cells, a health care professional may order additional                                                                                                tests:Blood test: A blood test involves drawing blood at a health care professional’s office or a commercial facility and sending the sample to a lab for analysis. A blood test can detect high levels of creatinine, a waste product of normal muscle breakdown, which may indicate kidney disease. Other blood tests may detect signs of autoimmune diseases, such as lupus, or other diseases, such as prostate cancer, which can cause hematuria.Computed tomography (CT) scan. CT scans use a combination of x-rays and computer technology to create images of the urinary tract, especially the kidneys. A health care professional may give the patient a solution to drink and an injection of contrast medium. CT scans can help a doctor diagnose stones in the urinary tract, obstructions, infections, cysts, tumors, and traumatic injuries.Cystoscopy: Cystoscopy is a procedure that a urologist — a doctor who specializes in urinary problems — performs to see inside the patient’s bladder and urethra using a cystoscope, a tubelike instrument.Kidney biopsy: Kidney biopsy is a procedure that involves taking a small piece of tissue from the kidney. A health care professional performs the biopsy in an outpatient centre or a hospital. The health care professional will give the patient light sedation and local anesthetic. In some cases, the patient will require general anesthesia. A pathologist — a doctor who specializes in diagnosing diseases — examines the tissue in a lab. The biopsy can help diagnose if the haematuria is due to kidney disease.• Magnetic resonance imaging (MRI). MRI is a test that takes pictures of the patient’s internal organs and soft tissues without using x-rays. During an MRI, the patient should remain perfectly still while the technician takes the images. During the procedure, the patient will hear loud mechanical knocking and humming noises coming from the machine. An MRI can help diagnose problems in individual internal organs, such as the bladder or kidney.Treatment: Treatment is aimed at the underlying cause. If your doctor finds the cause such as stones or kidney disease, you will be directed to specialist to deal with the disorder. If it is kidneydiseaseor  cancer, bladder cancer or prostate disease a referral to the appropriate specialist will be necessary.  Usually, no treatment is necessary unless a serious condition is causing the hematuria.If no underlying cause is found during the initial evaluation, you may be advised to have follow-up urine testing and blood pressure monitoring every three to six months, especially if you have risk factors for bladder cancer, such as being age 50 or older, smoking cigarettes, or exposure to certain industrial chemicals.Bibliography: Campbell’s Urology, Web MD —Mayo clinic.

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