What to Do When You Find Blood in the Urine

Blood in the urine is never normal. How bad a sign is it? As with most things in medicine, blood in the urine (hematuria) can be harmless or catastrophic. If you see blood when you pee, see a doctor, preferably a urologist, soon. Physicians categorize hematuria into gross and microscopic. Gross hematuria (not a judgment on your pee, just another way of saying visible) is usually more concerning and requires urgent workup. Microscopic hematuria is when your doctor tells you he or she sees it on a urine sample you've given.

Let's talk gross hematuria first. You wake up, you pee in the toilet and it's red or maybe even has clots in it. Often, there's no pain with hematuria. Next step is to call your doctor or find a urologist to visit soon.  As you're heading over to the clinic, you are thinking about what could have caused this to happen. If you had a beet salad last night, you may want to hold off on the doctor's visit as beets will certainly turn your urine pink to red and usually goes away by the end of the day. A urinary tract infection, especially in women, is the most common cause of hematuria. Unfortunately, another common cause of gross hematuria is bladder cancer, an often curable, if caught early, cancer that is much more common in cigarette smokers and chemical workers. Stones in the kidneys, ureters or bladder also cause gross hematuria. In men, urethral strictures, and prostate bleeding are also on the list.

Microscopic hematuria is far more common and usually less concerning. All of the above causes of gross hematuria can be seen in microscopic hematuria. Kidney disease and heavy exercise can also cause microscopic hematuria. Around 25% of the time, microscopic hematuria has no obvious cause but still needs evaluation to rule out the bad stuff.

How is the urologist going to evaluate hematuria? After a thorough patient interview and physical exam, focusing on exposure hazards such as smoking, industrial exposure, and stone risk, the urologist will most likely order a CT scan to image the kidneys, ureters, and bladder. He or she will also perform a cystoscopy which is a minor procedure where a flexible tube with a camera is inserted into the urethra to evaluate the urethra and bladder lining.  Most often, the urologist will apply a topical anesthetic to numb the urethra. The whole procedure usually takes about 2-3 minutes and most offices will let you watch the procedure on a digital monitor.  The CT scan will identify stones and tumors in the kidney and ureter and the cystoscopy will evaluate the lining of the bladder for tumors or other causes of bleeding. Your urine may also be tested for cancer cells with either a molecular test or a cytology examination interpreted by a pathologist.

What could go wrong with gross hematuria? As a practicing urologist, one of the things I emphasize is that all gross hematuria needs an evaluation. Even if the patient has a documented bladder infection, that may be only one cause of the bleeding. Many people have been given multiple rounds of antibiotics for recurring hematuria that is really a bladder cancer. If you see your primary physician and he or she does not refer you on to a urologist for gross hematuria, find a urologist for evaluation. Microscopic hematuria, as we discussed earlier, is usually less concerning and only needs evaluation if it's persistent on a few separate urine samples or if the patient is having other urinary symptoms such as flank pain, painful urination, incontinence or other urologic issues.

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