Evaluation of visible hematuria

Diseases

Summary

Visible (gross) hematuria is urine that is visibly discolored by blood or blood clot. It may present as urine that is red to brown, or as frank blood. As little as 1 mL of blood can impart color to 1 L of urine.

Visible hematuria, even when transient or asymptomatic, may indicate a significant disease process and always requires further investigation. Possible etiologies vary by age and the workup of visible hematuria differs among children, adults under the age of 35 years, and adults ages 35 years or older.

Patients with visible hematuria represent a higher-risk group for urologic malignancy than those presenting with nonvisible hematuria.[1] [2] [3] Visible hematuria is a presenting sign in more than 66% of patients with urologic cancer.[4] The sensitivity of visible hematuria in revealing malignancy is significant: 0.83 for urothelial carcinoma of the bladder, 0.66 for ureteric carcinoma, and 0.48 in renal cell carcinomas.[5] In men ages >60 years, the positive predictive value of visible hematuria for urologic malignancy is 22.1%, and in women of the same age it is 8.3%.[6]

Risk factors for urothelial carcinoma include:

Male sex
Age 35 years or older
Smoking
Exposures to benzene, aromatic amines, carcinogens, chemotherapy, or high doses of analgesics
A history of:
- Irritative voiding symptoms
- Chronic urinary tract infection
- Indwelling urinary catheter
- Pelvic irradiation.

Library

Bladder tumor visible on cystoscopy
CT of renal cell carcinoma (RCC) of the left kidney

Citations

Key Articles

Nielsen M, Qaseem A. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016 Apr 5;164(7):488-97.[Abstract][Full Text]
Morey AF, Broghammer JA, Hollowell CMP, et al. Urotrauma guideline 2020: AUA guideline. J Urol. 2021 Jan;205(1):30-5.[Abstract][Full Text]
European Association of Urology. EAU guidelines on urological trauma. Mar 2022 [internet publication].[Full Text]
American College of Radiology. ACR appropriateness criteria: hematuria. 2019 [internet publication].[Full Text]

Referenced Articles

1. Nielsen M, Qaseem A. Hematuria as a marker of occult urinary tract cancer: advice for high-value care from the American College of Physicians. Ann Intern Med. 2016 Apr 5;164(7):488-97.[Abstract][Full Text]
2. Kaag MG, Raman JD. Clinical guidelines: Clearing murky water - a guideline-based approach to haematuria. Nat Rev Urol. 2016 Apr 13;13(5):243-4.[Abstract]
3. Loo RK, Lieberman SF, Slezak JM, et al. Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria. Mayo Clin Proc. 2013 Jan 9;88(2):129-38.[Abstract]
4. Edwards TJ, Dickinson AJ, Natale S, et al. A prospective analysis of the diagnostic yield resulting from 4020 patients at a protocol-driven haematuria clinic. BJU Int. 2006 Feb;97(2):301-5.[Abstract]
5. Buntinx F, Wauters H. The diagnostic value of macroscopic haematuria in diagnosing urological cancers: a meta-analysis. Fam Pract. 1997 Feb;14(1):63-8.[Abstract][Full Text]
6. Hicks D, Li CY. Management of macroscopic haematuria in the emergency department. Postgrad Med J. 2008 Oct;84(996):539-44.[Abstract]
7. Dulku G, Shivananda A, Chakera A, et al. Painless visible haematuria in adults: an algorithmic approach guiding management. Cureus. 2019 Nov 13;11(11):e6140.[Abstract][Full Text]
8. Powles T, Bellmunt J, Comperat E, et al. Bladder cancer: ESMO clinical practice guideline for diagnosis, treatment and follow-up. Ann Oncol. 2022 Mar;33(3):244-58.[Abstract][Full Text]
9. Rouprêt M, Babjuk M, Compérat E, et al. European Association of Urology guidelines on upper urinary tract urothelial cell carcinoma: 2015 Update. Eur Urol. 2015 Nov;68(5):868-79.[Abstract]
10. Tanagho EA, McAninch JW. Smith's general urology, 16th ed. New York, NY: McGraw-Hill; 2003.
11. Morey AF, Broghammer JA, Hollowell CMP, et al. Urotrauma guideline 2020: AUA guideline. J Urol. 2021 Jan;205(1):30-5.[Abstract][Full Text]
12. Avey G, Blackmore CC, Wessells H, et al. Radiographic and clinical predictors of bladder rupture in blunt trauma patients with pelvic fracture. Acad Radiol. 2006 May;13(5):573-9.[Abstract]
13. Velazquez N, Fantus RJ, Fantus RJ, et al. Blunt trauma pelvic fracture-associated genitourinary and concomitant lower gastrointestinal injury: incidence, morbidity, and mortality. World J Urol. 2020 Jan;38(1):231-8.[Abstract]
14. European Association of Urology. EAU guidelines on urological trauma. Mar 2022 [internet publication].[Full Text]
15. Macey MR, Raynor MC. Medical and surgical treatment modalities for lower urinary tract symptoms in the male patient secondary to benign prostatic hyperplasia: a review. Semin Intervent Radiol. 2016 Sep;33(3):217-23.[Abstract][Full Text]
16. Foley SJ, Soloman LZ, Wedderburn AW, et al. A prospective study of the natural history of hematuria associated with benign prostatic hyperplasia and the effect of finasteride. J Urol. 2000 Feb;163(2):496-8.[Abstract]
17. Nyman MA, Schwenk NM, Silverstein MD. Management of urinary retention: rapid versus gradual decompression and risk of complications. Mayo Clin Proc. 1997 Oct;72(10):951-6.[Abstract]
18. Subiela JD, Balla A, Bollo J, et al. Endovascular management of ureteroarterial fistula: single institution experience and systematic literature review. Vasc Endovascular Surg. 2018 Feb 26;52(4):275-86.[Abstract]
19. Jiang S, Wang Y, Zhang Z, et al. Accuracy of hematuria for predicting non-diabetic renal disease in patients with diabetes and kidney disease: A systematic review and meta-analysis. Diabetes Res Clin Pract. 2018 Sep;143:288-300.[Abstract]
20. De Costa C, McLaughlin K, Noseworthy TW. Criteria for referring patients with renal disease for nephrology consultation: a review of the literature. J Nephrol. 2010 Jul-Aug;23(4):399-407.[Abstract]
21. Bhatt NR, Davis NF, Nolan WJ, et al. Incidence of visible hematuria among antithrombotic agents: a systematic review of over 175,000 patients. Urology. 2018 Apr;114:27-32.[Abstract]
22. Mariani AJ. The evaluation of adult hematuria: a clinical update. In: AUA update series 1998; volume XVII, lesson 24. Houston, TX: AUA Office of Education; 1998:185-92.
23. Leapman MS, Hall SJ, Stone NN, et al. Haematuria after prostate brachytherapy. BJU Int. 2013 Jan 29;111(8):E319-24.[Abstract][Full Text]
24. Barnes H, Holland AE, Westall GP, et al. Cyclophosphamide for connective tissue disease-associated interstitial lung disease. Cochrane Database Syst Rev. 2018 Jan 3;(1):CD010908.[Abstract][Full Text]
25. Moharamzadeh P, Ojaghihaghighi S, Amjadi M, et al. Effect of tranexamic acid on gross hematuria: a pilot randomized clinical trial study. Am J Emerg Med. 2017 Sep 9;35(12):1922-5.[Abstract]
26. O'Connor E, McVey A, Demkiw S, et al. Assessment and management of haematuria in the general practice setting. Aust J Gen Pract. 2021 Jul;50(7):467-71.[Abstract][Full Text]
27. Lucca I, Klatte T, Fajkovic H, et al. Gender differences in incidence and outcomes of urothelial and kidney cancer. Nat Rev Urol. 2015 Oct;12(10):585-92.[Abstract]
28. Yeoh M, Lai NK, Anderson D, et al. Macroscopic haematuria - a urological approach. Aust Fam Physician. 2013 Mar;42(3):123-6.[Abstract][Full Text]
29. Moloney F, Murphy KP, Twomey M, et al. Haematuria: an imaging guide. Adv Urol. 2014;2014:414125.[Abstract][Full Text]
30. Luciano RL, Perazella MA. Aristolochic acid nephropathy: epidemiology, clinical presentation, and treatment. Drug Saf. 2015 Jan;38(1):55-64.[Abstract]
31. Sing RI, Singal RK. What is significant hematuria for the primary care physician? Can J Urol. 2012 Oct;19(suppl 1):36-41.[Abstract][Full Text]
32. Bagnall P. Haematuria: classification, causes and investigations. Br J Nurs. 2014 Nov 6-26;23(20):1074-8.[Abstract]
33. Tasian GE, Jemielita T, Goldfarb DS, et al. Oral antibiotic exposure and kidney stone disease. J Am Soc Nephrol. 2018 May 10;29(6):1731-40.[Abstract]
34. Barocas DA, Boorjian SA, Alvarez RD, et al. Microhematuria: AUA/SUFU guideline. J Urol. 2020 Oct;204(4):778-86.[Abstract][Full Text]
35. Grossfeld GD, Litwin MS, Wolf JS, et al. Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy - part II: patient evaluation, cytology, voided markers, imaging, cystoscopy, nephrology evaluation, and follow-up. Urology. 2001 Apr;57(4):604-10.[Abstract]
36. American College of Radiology. ACR appropriateness criteria: hematuria. 2019 [internet publication].[Full Text]
37. National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. Jan 2019 [internet publication].[Full Text]
38. Kravchick S, Cherniavsky E, Verchovsky G, et al. Multidetector computed tomographic urography (MDCTU): its practical role in diagnosis of upper tract urothelial cancer in patients 50 years and older with different types of hematuria. Pathol Oncol Res. 2019 Jan;25(1):249-54.[Abstract]
39. Chlapoutakis K, Theocharopoulos N, Yarmenitis S, et al. Performance of computed tomographic urography in diagnosis of upper urinary tract urothelial carcinoma, in patients presenting with hematuria: systematic review and meta-analysis. Eur J Radiol. 2010 Feb;73(2):334-8.[Abstract]
40. Wang LJ, Wong YC, Huang CC, et al. Multidetector computerized tomography urography is more accurate than excretory urography for diagnosing transitional cell carcinoma of the upper urinary tract in adults with hematuria. J Urol. 2010 Jan;183(1):48-55.[Abstract]
41. Van Der Molen AJ, Cowan NC, Mueller-Lisse UG, et al; CT Urography Working Group of the European Society of Urogenital Radiology (ESUR). CT urography: definition, indications and techniques: a guideline for clinical practice. Eur Radiol. 2008 Jan;18(1):4-17.[Abstract]
42. Mehran R, Nikolsky E. Contrast-induced nephropathy: definition, epidemiology, and patients at risk. Kidney Int Suppl. 2006 Apr;(100):S11-5.[Abstract]
43. American College of Radiology. ACR appropriateness criteria: hematuria - child. 2018 [internet publication].[Full Text]
44. Paner GP, Zehnder P, Amin AM, et al. Urothelial neoplasms of the urinary bladder occurring in young adult and pediatric patients: a comprehensive review of literature with implications for patient management. Adv Anat Pathol. 2011 Jan;18(1):79-89.[Abstract]
45. Silverman SG, Leyendecker JR, Amis ES Jr. What is the current role of CT urography and MR urography in the evaluation of the urinary tract? Radiology. 2009 Feb;250(2):309-23.[Abstract][Full Text]
46. Yecies T, Bandari J, Macleod L, et al. Evaluation of the risks and benefits of computed tomography urography for assessment of gross hematuria. Urology. 2019 Nov;133:40-5.[Abstract]
47. Sourtzis S, Thibeau JF, Damry N, et al. Radiologic investigation of renal colic: unenhanced helical CT compared with excretory urography. AJR Am J Roentgenol. 1999 Jun;172(6):1491-4.[Abstract]
48. Willis SR, Ahmed HU, Moore CM, et al. Multiparametric MRI followed by targeted prostate biopsy for men with suspected prostate cancer: a clinical decision analysis. BMJ Open. 2014 Jun 15;4(6):e004895.[Abstract][Full Text]
49. Drost FH, Osses DF, Nieboer D, et al. Prostate MRI, with or without MRI-targeted biopsy, and systematic biopsy for detecting prostate cancer. Cochrane Database Syst Rev. 2019 Apr 25;(4):CD012663.[Abstract][Full Text]
50. Ngo B, Papa N, Perera M, et al. Bladder cancer diagnosis during haematuria investigation - implications for practice guidelines. BJU Int. 2017 May;119 Suppl 5:53-4.[Abstract][Full Text]
51. Escudier B, Porta C, Schmidinger M, et al. Renal cell carcinoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2019 May 1;30(5):706-20.[Abstract][Full Text]
52. Simundic AM, Bölenius K, Cadamuro J, et al. Joint EFLM-COLABIOCLI recommendation for venous blood sampling. Clin Chem Lab Med. 2018;56(12):2015-38.[Abstract]
53. Pappas PG. Laboratory in the diagnosis and management of urinary tract infections. Med Clin North Am. 1991 Mar;75(2):313-25.[Abstract]
54. Maier U, Simak R, Neuhold N. The clinical value of urinary cytology: 12 years of experience with 615 patients. J Clin Pathol. 1995 Apr;48(4):314-7.[Abstract]
55. National Institute for Health and Care Excellence. Prostate cancer: diagnosis and management. December 2021 [internet publication].[Full Text]
56. Harada T, Abe T, Kato F, et al. Five-point Likert scaling on MRI predicts clinically significant prostate carcinoma. BMC Urol. 2015 Sep 4;15:91.[Abstract][Full Text]
57. Morey AF, McAninch JW, Tiller BK, et al. Single shot intraoperative excretory urography for the immediate evaluation of renal trauma. J Urol. 1999 Apr;161(4):1088-92.[Abstract]
58. American College of Radiology. ACR appropriateness criteria: penetrating trauma - lower abdomen and pelvis. 2019 [internet publication].[Full Text]
59. Colville DJ, Savige J. Alport syndrome. A review of the ocular manifestations. Ophthalmic Genet. 1997 Dec;18(4):161-73.[Abstract]
60. Lewinsohn DM, Leonard MK, LoBue PA, et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children. Clin Infect Dis. 2017 Jan 15;64(2):e1-33.[Abstract][Full Text]
61. Nataraj G, Kurup S, Pandit A, et al. Correlation of fine needle aspiration cytology, smear and culture in tuberculous lymphadenitis: a prospective study. J Postgrad Med. 2002 Apr-Jun;48(2):113-6.[Abstract][Full Text]
62. Muneer A, Macrae B, Krishnamoorthy S, et al. Urogenital tuberculosis - epidemiology, pathogenesis and clinical features. Nat Rev Urol. 2019 Oct;16(10):573-98.[Abstract][Full Text]
63. Geldmacher H, Taube C, Kroeger C, et al. Assessment of lymph node tuberculosis in northern Germany: a clinical review. Chest. 2002 Apr;121(4):1177-82.[Abstract]
64. Weir MR, Thornton GF. Extrapulmonary tuberculosis. Experience of a community hospital and review of the literature. Am J Med. 1985 Oct;79(4):467-78.[Abstract]
65. Baydur A. The spectrum of extrapulmonary tuberculosis. West J Med. 1977 Apr;126(4):253-62.[Abstract][Full Text]
66. World Health Organization. WHO consolidated guidelines on tuberculosis: module 3: diagnosis: rapid diagnostics for tuberculosis detection. Mar 2024 [internet publication].[Full Text]
67. Bjerrum S, Schiller I, Dendukuri N, et al. Lateral flow urine lipoarabinomannan assay for detecting active tuberculosis in people living with HIV. Cochrane Database Syst Rev. 2019 Oct 21;10(10):CD011420.[Abstract][Full Text]
68. Warshauer DM, McCarthy SM, Street L, et al. Detection of renal masses: sensitivities and specificities of excretory urography/linear tomography, US, and CT. Radiology. 1988 Nov;169(2):363-5.[Abstract]
69. Dong XQ, Shen Y, Xu LW, et al. Contrast-enhanced ultrasound for detection and diagnosis of renal clear cell carcinoma. Chin Med J (Engl). 2009 May 20;122(10):1179-83.[Abstract]
70. Heidenreich A, Ravery V; European Society of Oncological Urology. Preoperative imaging in renal cell cancer. World J Urol. 2004 Nov;22(5):307-15.[Abstract]
71. Silverman SG, Israel GM, Herts BR, et al. Management of the incidental renal mass. Radiology. 2008 Oct;249(1):16-31.[Abstract]
72. Swartz MA, Porter MP, Lin DW, et al. Incidence of primary urethral carcinoma in the United States. Urology. 2006 Dec 4;68(6):1164-8.[Abstract]
73. Grellety T, Houédé N, Hoepffner JL, et al. Hemorrhagic cystitis in patients treated with cabazitaxel: a radiation recall syndrome? Ann Oncol. 2014 Apr 1;25(6):1248-9.[Abstract][Full Text]