All patients with macroscopic haematuria need to be referred promptly.
They should be investigated with:
- Assuming the haematuria has ceased, urine cytology on three separate days, avoiding the first void of the morning. Urine that has been sitting in the bladder overnight or for long periods often gives false positive results as the cells always look abnormal. If there is persistent macroscopic haematuria urine cytology is not required as the blood in the urine will also make the results meaningless.
- CT renal with contrast and delayed images (also called CT Urogram). Patients with renal impairment or contrast allergy can have a non contrast CT.
- On referral they will be booked for a cystoscopy. If the patient was unable to have a contrast CT then retrograde pyelogram will also be performed, where contrast material is injected up the ureters to image the lining of the ureters and kidneys.
Malignant causes of haematuria include urothelial carcinoma (aka TCC or transitional cell carcinoma) anywhere in the urinary tract (kidneys, ureters, bladder or even prostatic urethra) or renal cell carcinoma.
Benign causes include benign prostatic bleeding, radiation cystitis, urinary tract infection and renal, ureteric or bladder calculi.
Obtaining imaging and/or cytology before they see a urologist will expedite their treatment.
The evaluation is the same with
- Urine cytology x3
- CT urogram
In younger patients it is reasonable to repeat the MSU 2 or 3 times. If subsequent urine microscopies do not show blood then further evaluation is not required. This only applies to young non smokers in the teens and early twenties. I tend to investigate everyone else completely to ensure that an abnormality is not missed.