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Macroscopic or visible haematuria

What is Macroscopic Haematuria?

Macroscopic haematuria means that there is visible blood in the urine causing it to be discoloured pink, red, brownish-red or tea-coloured. Gross haematuria is another term for visible blood in the urine.

Although seeing blood in the urine with visible or macroscopic haematuria can be frightening, most of the time blood in the urine is not life threatening. The important thing is not to ignore the symptom of haematuria and to have it investigated because it can sometimes be caused by a serious condition in the urinary tract.

Even a single episode of visible blood in the urine warrants further investigation to exclude significant pathology such as a cancer in the urinary tract.

What is the significance of Haematuria?

Not all haematuria is caused by significant problems in the urinary tract.

Studies have shown that even with extensive investigation that a specific cause for the haematuria is not found in up to 50% of patients with macroscopic haematuria.

Haematuria requires investigation to exclude significant or worrying pathology in the urinary tract.

Macroscopic or visible haematuria is more concerning than microscopic (invisible) haematuria. Cases of macroscopic haematuria (including even one episode of visible blood in the urine) require thorough investigation because of the significant rate of urinary tract cancers found in people with visible blood in the urine. The prevalence of urinary tract cancers in people presenting with the symptom of visible blood in the urine ranges between 3 to 6% but has been reported to be as high as 19% in some studies.

Risk factors for Urinary Tract Cancers

Risk factors for urinary tract cancers (or malignancy) include:

  • Increasing age especially > 40 years
  • History of smoking (both current and past)
  • Occupational exposure to dyes in the print and clothing industries, benzenes
  • Exposure to medications such as cyclophosphamide and phenacetin
  • Previous pelvic radiation
  • History of macroscopic or visible haematuria
  • Significant bladder symptoms in the absence of a urinary infection such as urgency, frequency, pain or discomfort on urination

Initial treatment of Macroscopic Haematuria

Thankfully most episodes of macroscopic haematuria are brief and will settle with conservative management such as increasing fluid intake.

In cases of severe macroscopic haematuria associated with passage of multiple blood clots in the urine, urgent assessment is required to check the level of bleeding.

The most common emergency presentation of severe macroscopic haematuria is with urinary retention (or inability to pass urine) due to blockage of the flow of urine by blood clots. Patients can present with severe abdominal pain and an inability to pass urine due the blood clots (called clot retention). Emergency treatment involves passage of a catheter into the bladder to drain urine and a washout of blood clots from the bladder with irrigation of the bladder with sterile fluid via the catheter. Sometimes an emergency cystoscopy is required to washout clot from the bladder and diathermy any active bleeding points.

All patients with an episode of macroscopic haematuria require a cystoscopy at some stage as well further investigations for the haematuria to determine and treat the underlying cause.