SCE Urology: Mastering Haematuria Diagnosis & Management

As medical professionals, we frequently encounter patients presenting with haematuria, a symptom that can range from benign to life-threatening. For candidates preparing for the Specialty Certificate Examination (SCE) in various medical specialties, a solid understanding of haematuria – its causes, investigation, and management – is absolutely critical. It's a high-yield topic, often tested due to its clinical significance and the need for a structured approach.

What is Haematuria?

Haematuria is simply the presence of blood in the urine. It's broadly classified into two types:

1. Macroscopic (Gross) Haematuria: Visible blood in the urine, often leading to red, pink, or cola-coloured urine. Patients typically present promptly due to alarm.

2. Microscopic Haematuria: Not visible to the naked eye, detected only by urine dipstick or microscopy (defined as ≥3 red blood cells per high-power field on two out of three urine specimens).

While macroscopic haematuria is a clear indicator, microscopic haematuria can be an incidental finding, but both warrant careful evaluation.

Causes of Haematuria: A Broad Differential

Haematuria can originate from any point in the urinary tract, from the kidney parenchyma down to the urethra. Causes can be broadly categorised:

• Urological Malignancy (Most Concerning): Bladder cancer, kidney cancer, prostate cancer (in men), and ureteric cancer. This risk significantly increases with age, smoking history, and certain occupational exposures. Always exclude malignancy first, especially in older patients with painless macroscopic haematuria.

• Infections: Urinary tract infections (UTIs) are a very common cause, especially in women. Pyelonephritis, prostatitis, and even sexually transmitted infections can cause haematuria.

• Calculi (Stones): Kidney stones or bladder stones can cause trauma and bleeding, often accompanied by severe flank pain (renal colic).

• Glomerular Disease (Nephrological): Conditions affecting the kidney's filtering units, such as IgA nephropathy, post-streptococcal glomerulonephritis, Alport syndrome, and other vasculitides. This often presents with dysmorphic red blood cells or red cell casts on microscopy, and proteinuria.

• Trauma: Direct injury to the kidneys, bladder, or urethra.

• Benign Prostatic Hyperplasia (BPH): Common in older men, enlarged prostate can lead to bladder neck congestion and bleeding.

• Medical Conditions/Medications: Anticoagulants (e.g., warfarin, DOACs), antiplatelet agents, sickle cell trait/disease, polycystic kidney disease, and sometimes vigorous exercise.

• Other Rare Causes: Arteriovenous malformations, certain systemic diseases (e.g., amyloidosis), or drug-induced interstitial nephritis.

The SCE-Relevant Clinical Approach: History & Examination

Your SCE preparation requires a systematic approach. For haematuria, this means a thorough history and targeted examination:

Key History Points:

• Onset and Duration: When did it start? Is it persistent or intermittent?

• Colour and Consistency: Bright red, dark, clots? Clots suggest macroscopic bleeding from the lower urinary tract.

• Timing: Is the blood present throughout urination (total haematuria), at the beginning (initial haematuria - suggests urethral origin), or at the end (terminal haematuria - suggests bladder neck/prostatic urethra origin)?

• Associated Symptoms:

  • Pain: Dysuria (infection), flank pain (stones/pyelonephritis), suprapubic pain (cystitis).

  • Urinary frequency, urgency, nocturia (BPH, UTI, bladder irritation).

  • Systemic symptoms: Fever, chills (infection), weight loss, night sweats, fatigue (malignancy).

  • Lower limb oedema, foamy urine (glomerular disease).

• Risk Factors for Malignancy: Smoking history (current or past), occupational exposure (dyes, chemicals), cyclophosphamide use, chronic bladder irritation, recurrent UTIs.

• Medication Review: Especially anticoagulants, NSAIDs.

• Past Medical History: Diabetes, hypertension, kidney disease, stone history, previous urological procedures.

• Family History: Renal disease, bleeding disorders.

Targeted Examination:

• General: Vital signs (BP, temperature), pallor, oedema.

• Abdominal: Palpate for masses (kidney, bladder), tenderness.

• Digital Rectal Examination (DRE): In men, to assess prostate size, consistency, and any nodules (for BPH or prostate cancer).

• Genital Examination: To look for urethral lesions or discharge.

Investigations for Haematuria: SCE Essentials

Investigations aim to identify the cause and rule out malignancy. The urgency of investigation depends on the presentation (e.g., macroscopic haematuria, especially painless, warrants urgent referral).

1. Urine Tests:

   • Urinalysis (Dipstick): Initial screening. Note: Can be falsely positive (e.g., myoglobinuria, beetroot). Confirm with microscopy.

   • Urine Microscopy: Crucial to confirm red blood cells and identify dysmorphic red cells or casts (suggestive of glomerular disease).

   • Urine Culture & Sensitivity (MC&S): To rule out UTI.

   • Urine Cytology: May be helpful in detecting high-grade bladder malignancy, but sensitivity is variable and often not the primary diagnostic tool.

2. Blood Tests:

   • Full Blood Count (FBC): To assess for anaemia.

   • Renal Function Tests (U&Es/Creatinine): To assess kidney function, especially if a nephrological cause is suspected.

   • Coagulation Profile: If a bleeding disorder or anticoagulant use is suspected.

   • PSA (Prostate Specific Antigen): In men, if prostate pathology is suspected, especially if over 50 years old or with prostate symptoms (interpret carefully, as it can be raised in BPH or infection).

   • Serology: If systemic or glomerular disease is suspected (e.g., ANCA, ANA, C3/C4, anti-GBM antibodies).

3. Imaging:

   • Renal Ultrasound: Good initial screening for kidney and bladder pathology (hydronephrosis, masses, stones).

   • CT Urography (CTU): Often the imaging modality of choice for evaluating the entire urinary tract (kidneys, ureters, bladder) for stones, masses, and other structural abnormalities. It provides excellent anatomical detail.

   • MRI Urography: Can be used as an alternative to CTU, especially if radiation exposure is a concern (e.g., younger patients, pregnant patients).

4. Endoscopy:

   • Cystoscopy: The gold standard for evaluating the lower urinary tract (bladder and urethra). It allows direct visualisation and biopsy of any suspicious lesions. Essential for all patients with unexplained macroscopic haematuria and often for persistent microscopic haematuria after other investigations.

Management Principles

Management of haematuria is dictated by the underlying cause:

• Malignancy: Urgent referral to urology for definitive diagnosis (biopsy) and staging, followed by appropriate oncological management (surgery, chemotherapy, radiotherapy).

• Infections: Antibiotics based on culture and sensitivity.

• Calculi: Pain management, hydration, medical expulsive therapy (for smaller stones), or surgical intervention (lithotripsy, ureteroscopy) for larger or symptomatic stones.

• Glomerular Disease: Referral to nephrology for specific diagnosis and management, which may involve immunosuppressants.

• BPH: Medical management (alpha-blockers, 5-alpha-reductase inhibitors) or surgical options (TURP).

• Anticoagulant-induced: Review and adjust medication if possible, but never assume it's solely due to anticoagulation without full workup, especially for new-onset haematuria – malignancy must still be excluded.

SCE Success: Key Takeaways

• Always exclude malignancy: Especially in patients >40-50 years old with unexplained, painless macroscopic haematuria. This requires urgent referral (e.g., two-week wait pathway in the UK).

• Painless haematuria is ominous: Often associated with malignancy until proven otherwise.

• Understand the diagnostic algorithm: Start with urine tests, then imaging (CTU), and finally direct visualisation (cystoscopy) if indicated.

• Differentiate glomerular from non-glomerular: Look for dysmorphic RBCs, casts, and proteinuria (suggesting glomerular disease, requiring nephrology input).

• Know the red flag symptoms: Painless gross haematuria, persistent microscopic haematuria, associated weight loss, smoking history.

• Don't attribute haematuria solely to anticoagulants: A full urological workup is still necessary.

Mastering the systematic approach to haematuria will not only ensure you're well-prepared for your SCE exams but also equip you with essential clinical skills for managing one of the most common and potentially serious presentations in urological practice. Good luck with your studies!