(1)
Royal Free NHS Foundation Trust, London, UK
Causes of red urine
Macroscopic haematuria
Haemoglobinuria (haemolysis)
Myoglobinuria
Drugs: rifampicin; metronidazole; warfarin; nitrofurantoin
Menstruation
Food: beetroot (anthrocyanin); red cabbage; blackberries; food colourants (paprika; rhodamine B)
Urate crystals: ‘brick dust’ in a baby’s nappy
Types of haematuria
The timing of haematuria during micturition is an aid in the localization of the source of bleeding.
Initial: anterior urethra
Terminal: posterior urethra; bladder, including neck and trigone; prostate; seminal vesicles
Total: bladder; upper urinary tract (kidney or ureter)
Checklist for haematuria assessment
Timing: initial, total, terminal
Lower urinary tract symptoms: dysuria, increased urinary frequency, urgency, urethral discharge
Obstructive urinary symptoms: hesitancy, straining to void, sensation of incomplete emptying
Flank pain: renal stone disease; pyelonephritis
Suprabic pain: bladder outlet obstruction; haemorrhagic cystitis
Signs associated with glomerular origin: peripheral and periorbital oedema; oliguria; hypertension; weight gain
Features of vasculitis: skin rash; arthralgia; fever
Recent urological intervention, such as bladder catheterization, prostate biopsy, ureteral stent placement, nephrostomy, or trans-urethral surgery
Drug history: anticoagulants; nephrotoxic medications (eg NSAIDs)
Family history of renal disease
Occupational history: exposure to chemicals and smoking
Travel history
Urine dip stick analysis for blood, protein, leucocytes, nitrites. Dipstick tests do not distinguish between intact red blood cells, free haemoglobin or free myoglobin.
Urine microscopy for red blood cells; red cell casts; dysmorphic red blood cells. Three or more red blood cells per high power field on at least two out of three correctly collected urine specimens indicates microscopic haematuria.
Renal function: plasma creatinine/eGFR
Upper urinary tract imaging: CT scan
Red flags with haematuria
Painless macroscopic haematuria (which has a high diagnostic yield for urological malignancy)
Symptomatic microscopic haematuria in absence of urinary tract infection
Unexplained microscopic haematuria in patient aged >50 years
Causes of haematuria
Glomerular disease
IgA nephropathy (Berger’s disease)
Acute post-infectious glomerulonephritis (nephritogenic strains of Group A streptococcus) (hypertension; skin rash)
Alport’s syndrome (hereditary nephritis)
Membrano-proliferative glomerulonephritis
Systemic vasculitis/ lupus
Thin glomerular basement membrane disease (benign familial haematuria)
Rapidly progressive glomerulonephritis
Non-glomerular
Upper urinary tract (kidney and ureter)
Tumours: renal cell carcinoma; transitional cell carcinoma.
Medullary/ interstitial disease: papillary necrosis; medullary sponge kidney; tuberculosis
Urolithiasis
Trauma to kidneys/ureters
Miscellaneous
Arterio-venous malformation
Loin pain-haematuria syndrome (recurent loin pain and intermittent macroscopic or microscopic haemturia); nutcracker syndrome (compression of left renal vein between abdominal aorta and superior mesenteric artery)
Renal artery thrombosis
Hereditary haemorrhagic telangiectasia
Lower urinary tract (bladder and urethra)
Bladder: haemorrhagic cystitis; transitional cell carcinoma; stone; schistosomiasis; radiation cystitis
Prostate: benign prostatic hyperplasia; cancer; prostatitis
Urethra: urethritis
Coagulopathies: anticoagulants; haemophilia; sickle cell disease
Features suggesting glomerular origin of haematuria
A fresh, midstream, clean-catch or cather specimen of urine should be analysed
Smoky brown coloured urine; no clots
Red blood cell casts
Dysmorphic red blood cells
Significant proteinuria (>500 mg/24 h)
Risk factors for urothelial cancer presenting with haematuria
Age > 40 years
Male gender
History of cigarette smoking, past or current
History of occupational chemical or dye exposure (aromatic amines, benzenes)
Cyclophosphamide therapy
History of pelvic radiation
Chronic irritative voiding lower urinary tract symptoms (urgency, frequency, dysuria, nocturia, hesitancy, sensation of incomplete emptying)
Prior urological disease or treatment
Chronic indwelling foreign body
Retention of urine
Urinary retention can be acute or chronic. Acute urinary retention refers to the sudden inability to pass urine and empty the bladder during voluntary voiding.
Causes of acute urinary retention
Anatomical causes resulting in mechanical obstruction to the flow of urine
Penis: phimosis; paraphimosis; foreign body constriction
Urethra: foreign body, calculus; urethritis; stricture; tumour; thrombosed urethral caruncle; meatal stenosis; pelvic trauma with disruption of posterior urethra or bladder neck; peri-urethral abscess
Extrinsic compression: pelvic mass (gynaecological malignancy, ovarian cyst, uterine fibroid); pelvic organ prolapse (cystocele, rectocele, uterine prolapse); haematoma; retroverted impacted gravid uterus; faecal impaction (causing pressure on the bladder trigone)
Prostate: benign prostatic hyperplasia; cancer; prostatitis; bladder neck contracture; prostatic infarction; prostatic abscess
Neuropathic Causes
Motor/paralytic: spinal shock; spinal cord syndromes; cauda equina syndrome
Sensory/ paralytic: diabetes mellitus; multiple sclerosis; spinal cord syndromes
Drugs causing dynamic obstruction to urine flow: anticholinergic, anti-spasmodic, tricyclic antidepressants, alpha-adrenergic agonists, antihistamines, opiates, anti-psychotics.
Infective/inflammatory: urinary tract infection; acute vulvovaginitis; genital herpes.
Causes of acute urinary retention in women
Neurological:
Diabetes mellitus
Multiple sclerosis
Spinal cord lesions: trauma, tumours
Transverse myelitis
Cerebrovascular accident
Fowler’s syndrome: impaired relaxation of external sphincter in post-menopausal women
Non-neurological:
Urethral Obstruction:
Cystocoele; rectocoele; uterine prolapse
Stricture; diverticulum
Previous incontinence surgery
Herpetic vulvo-vaginitis
Previous total abdominal hysterectomy
Lower urinary tract symptoms in men which can be predictive for the development of acute urinary retention
Storage symptoms: frequency; urgency; nocturia; incontinence
Voiding symptoms: slow stream; spraying; intermittent flow; terminal dribbling
Post-micturition symptoms: incomplete emptying; dribbling
Urinary retention checklist
Time of last voiding
Previous episodes of acute urinary retention
Preceding lower urinary tract symptoms
Haematuria, leading to clot retention
Neurological symptoms and signs
Drug history
Constipation
Recent abdominal or pelvic surgery
Bladder distension, recognized by a palpable tender suprapubic mass and confirmed on bedside ultrasound scan
Urine dip stick analysis
Renal function
Bladder ultrasound for residual urine post-voiding
Digital rectal examination after catherisation to evaluate anal tone, size and texture of the prostate, presence of faecal impaction
Complications of long-term indwelling urethral catheters presenting in emergency practice
Blocked catheter: encrustation (crystal precipitation), often associated with urease-producing bacteria (Proteus mirabilis); kinks; stones
Infection (asymptomatic bacteriuria; urethritis; cystitis; pyelonephritis; seminal vesiculitis; epididymo-orchitis; bacteraemia; urosepsis). Catheter-related infection can present with
Fever < 38.4 degrees centigrade
Unusually cloudy urine
Mental state changes
More frequent catheter blockage
Increased detrusor spasms
Hypotension
>5–10 WBCs per high-power field on microscopy
Gross haematuria
Leakage of urine (bypassing) around catheter: detrusor overactivity causing spasms (overactive bladder, cystitis, bladder outlet obstruction) (may respond to anticholinergic medication); catheter blockage
Failure of balloon deflation: secondary lumen obstruction; valve malfunction (cut off side-arm and remove valve)
Paraphimosis
Causes of renal pain
Urinary obstruction
Calculus
Necrotic papilla
Blood clot
Tumour
Pelvi-ureteric junction dyssynergia
Rapid renal swelling
Acute pyelonephritis
Bleeding into renal cystRelated posts:
Full access? Get Clinical Tree
