Medicine – Causes of Haematuria

Haematuria means the presence of red blood cells in the urine. It may be visible (macroscopic/gross) or detected only on testing as microscopic haematuria.

The most useful first distinction is whether the bleeding is:

Glomerular — arising from the renal glomeruli.

or

Non-glomerular — arising from the renal pelvis, ureter, bladder, prostate, urethra or other urinary structures.

1. Urinary Tract Infection

A urinary tract infection is a common cause of haematuria.

Inflammation of the urinary mucosa can cause:

Microscopic or visible blood in the urine.

Typical associated symptoms include:

Dysuria.

Frequency.

Urgency.

Suprapubic discomfort.

Pyelonephritis

If infection involves the kidney, patients may develop:

Fever.

Flank pain.

Pyuria.

Bacteriuria.

WBC casts.

Haematuria may also occur.

2. Urinary Tract Malignancy

An important cause of haematuria is:

Urinary tract malignancy.

Examples include:

Bladder cancer.

Renal cell carcinoma.

Upper urinary tract urothelial carcinoma.

Painless Visible Haematuria

A classic warning feature is:

Painless visible haematuria.

This should prompt evaluation for:

Urinary tract malignancy, especially in older adults or patients with relevant risk factors such as smoking.

Therefore:

PAINLESS VISIBLE HAEMATURIA → EXCLUDE URINARY TRACT CANCER.

3. Renal Calculi

Kidney and ureteric stones commonly produce:

Haematuria.

This may be microscopic or visible.

Typical associated symptoms include:

Severe colicky loin-to-groin pain.

Restlessness.

Nausea or vomiting.

Mechanism

A calculus damages or irritates the urinary epithelium as it moves through the urinary tract.

This causes:

Local bleeding

and therefore:

Haematuria.

4. Acute Glomerulonephritis

Acute glomerulonephritis produces:

Glomerular haematuria.

The urine may appear:

Tea-coloured or cola-coloured.

Other typical findings include:

Proteinuria.

Dysmorphic RBCs.

Red-cell casts.

Hypertension.

Reduced GFR.

5. Glomerular Versus Non-Glomerular Haematuria

Glomerular haematuria tends to be associated with:

Dysmorphic RBCs.

Acanthocytes.

RBC casts.

Proteinuria.

Non-glomerular haematuria is more likely to show:

Uniform RBCs.

Blood clots.

Little or no significant proteinuria.

This distinction is very useful clinically.

6. IgA Nephropathy

IgA nephropathy is an important glomerular cause of haematuria.

A classic presentation is:

Visible haematuria during or within a few days of an upper respiratory infection.

This is known as:

Synpharyngitic haematuria.

IgA Nephropathy Pattern

The timing is important:

Upper respiratory infection

↓

Haematuria occurs immediately or within days

↓

Think IgA nephropathy.

This contrasts with post-streptococcal GN, where haematuria usually follows the infection after a latent interval.

7. Interstitial Nephritis

Acute interstitial nephritis – AIN can cause:

Microscopic haematuria.

However, more characteristic findings include:

Sterile pyuria.

WBC casts.

Mild-to-moderate proteinuria.

AKI.

Drug-Induced AIN

AIN is often associated with medications such as:

Antibiotics.

NSAIDs.

Proton-pump inhibitors.

Haematuria can occur but is usually not the dominant feature.

8. Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease – ADPKD can cause haematuria.

This may result from:

Cyst rupture.

Bleeding into a cyst.

Urinary infection.

Associated renal calculi.

ADPKD Clues

Other features may include:

Hypertension.

Bilateral enlarged cystic kidneys.

Flank or abdominal pain.

Family history of kidney disease.

9. Renal Papillary Necrosis

Renal papillary necrosis involves ischaemic destruction of the renal papillae.

It can produce:

Haematuria.

Flank pain.

Passage of sloughed papillary tissue.

Urinary obstruction.

Causes of Papillary Necrosis

Important associations include:

Diabetes mellitus.

Analgesic/NSAID exposure.

Sickle cell disease or trait.

Severe pyelonephritis.

Urinary tract obstruction.

A traditional mnemonic is based around these major causes.

10. Hypertension

Severe hypertension can produce haematuria through:

Renal vascular and glomerular injury.

This is particularly relevant in:

Hypertensive emergency or accelerated hypertension.

Associated findings may include:

Proteinuria.

AKI.

Retinopathy.

Chronic Hypertension

Uncomplicated chronic hypertension is more commonly associated with:

Low-grade proteinuria

than prominent haematuria.

Therefore marked haematuria should prompt consideration of another renal or urinary cause.

11. Endometriosis

Endometriosis can rarely involve the:

Bladder or urinary tract.

If bladder endometriosis is present, the patient may develop:

Cyclical haematuria.

This means haematuria occurs in association with:

Menstruation.

Clinical Clue

Therefore:

HAEMATURIA RECURRING WITH MENSTRUATION → CONSIDER URINARY TRACT ENDOMETRIOSIS.

However, menstrual contamination of the urine specimen should also be excluded.

12. Factitious Haematuria

The older term:

Fictitious haematuria

usually refers to deliberately produced or falsely reported haematuria.

A more appropriate term is:

Factitious haematuria.

Possible mechanisms include deliberate contamination of the urine sample with:

Blood.

Important Approach

Factitious haematuria should only be considered after appropriate investigation and when the findings are inconsistent.

It is important not to assume a factitious cause before excluding genuine urinary disease.

13. Menstrual Contamination

An important common cause of apparent haematuria is:

Menstrual contamination.

Blood may enter the urine specimen during collection.

If this is suspected, urine testing can be repeated:

After menstruation

using a properly collected specimen.

14. Trauma

Trauma can produce haematuria by injuring:

Kidney.

Ureter.

Bladder.

Urethra.

Examples include:

Blunt abdominal trauma.

Pelvic fracture.

Instrumentation.

15. Anticoagulant Therapy

Anticoagulants can make urinary tract bleeding more likely or more obvious.

However:

Anticoagulation should not automatically be accepted as the sole explanation for haematuria.

An underlying lesion, including malignancy, may still be present and should be investigated appropriately.

16. Exercise-Induced Haematuria

Strenuous exercise can cause:

Transient microscopic or visible haematuria.

This usually resolves after exercise stops.

Persistent haematuria requires further evaluation.

17. Sickle Cell Disease and Trait

Sickle cell disease and sickle cell trait can cause haematuria through:

Renal medullary ischaemia.

They are also associated with:

Papillary necrosis.

18. Benign Prostatic Disease

In men, prostate disorders can produce haematuria.

Examples include:

Benign prostatic enlargement.

Prostatitis.

Prostate malignancy.

The urinary symptoms and patient age help guide further investigation.

19. Glomerular Haematuria – Note Form

Acute GN:

Tea/cola-coloured urine.

Dysmorphic RBCs.

RBC casts.

Proteinuria.

IgA nephropathy:

Haematuria during or soon after an upper respiratory infection.

Other glomerular diseases:

Lupus nephritis.

ANCA-associated GN.

Anti-GBM disease.

Post-infectious GN.

20. Non-Glomerular Haematuria – Note Form

UTI:

Haematuria + pyuria + dysuria.

Calculi:

Haematuria + severe colicky pain.

Urinary malignancy:

Often painless visible haematuria.

ADPKD:

Cyst bleeding/rupture ± stones/infection.

Papillary necrosis:

Diabetes, analgesics/NSAIDs, sickling disorders and severe infection.

Endometriosis:

Cyclical haematuria associated with menstruation.

21. Urine Dipstick and Microscopy

A urine dipstick detects:

Haem pigment.

Therefore a positive blood result can be caused by:

Intact RBCs.

Haemoglobin.

Myoglobin.

Microscopy helps distinguish them.

Interpretation

Dipstick positive + RBCs present → haematuria.

Dipstick positive + few/no RBCs → think myoglobinuria or haemoglobinuria.

This is particularly important in:

Rhabdomyolysis

and

Intravascular haemolysis.

22. Red Cell Morphology

Red-cell morphology may help determine the source of haematuria.

Dysmorphic RBCs, particularly:

Acanthocytes,

suggest passage through an abnormal glomerular filtration barrier.

Therefore they support:

Glomerular haematuria.

23. Red Cell Casts

The presence of:

RBC casts

is particularly important.

Because casts form within renal tubules, RBC casts indicate bleeding originating within:

The kidney.

The major association is:

Glomerulonephritis.

24. Blood Clots

Visible blood clots usually suggest:

Non-glomerular bleeding.

This is because glomerular bleeding generally produces altered RBCs rather than large clots.

Therefore:

HAEMATURIA + CLOTS → THINK UROLOGICAL SOURCE.

25. Haematuria with Proteinuria

The combination:

Haematuria + significant proteinuria

raises suspicion of:

Glomerular disease.

This becomes even stronger if there are:

Dysmorphic RBCs.

RBC casts.

Reduced renal function.

26. Haematuria with Pain

Painful haematuria suggests causes such as:

Calculi.

UTI.

Pyelonephritis.

Trauma.

27. Painless Haematuria

Painless visible haematuria is particularly concerning for:

Urinary tract malignancy.

Therefore it should not be ignored even if it occurs only once.

28. Important Corrections to the Original Notes

Hypertension can cause haematuria, particularly when severe, but uncomplicated chronic hypertension is not one of the strongest causes of prominent haematuria.

Interstitial nephritis may produce microscopic haematuria, but the more characteristic urinary findings are:

STERILE PYURIA + WBC CASTS ± MILD PROTEINURIA.

The older term:

“Fictitious haematuria”

is better described as:

FACTITIOUS HAEMATURIA.

It should only be considered after genuine renal and urinary causes have been appropriately assessed.

An important additional cause is:

MENSTRUAL CONTAMINATION, which can mimic haematuria.

Other useful additions include:

Trauma.

Exercise.

Sickle cell disease/trait.

Prostatic disease.

Anticoagulant-associated bleeding, while still investigating for an underlying cause.

Key Clinical Pattern

For exams and clinical reasoning, remember:

HAEMATURIA + DYSURIA/PYURIA → UTI.

HAEMATURIA + SEVERE COLICKY PAIN → CALCULUS.

PAINLESS VISIBLE HAEMATURIA → EXCLUDE URINARY TRACT MALIGNANCY.

TEA/COLA URINE + PROTEINURIA + RBC CASTS → GLOMERULONEPHRITIS.

HAEMATURIA DURING/IMMEDIATELY AFTER URI → IgA NEPHROPATHY.

CYCLICAL HAEMATURIA WITH MENSTRUATION → CONSIDER URINARY ENDOMETRIOSIS.

HAEMATURIA + RBC CASTS/DYSMORPHIC RBCs → GLOMERULAR SOURCE.

HAEMATURIA + CLOTS → MORE LIKELY UROLOGICAL/NON-GLOMERULAR SOURCE.