I have blood in my urine!

THIS can be quite alarming if it occurs to you. The medical term for blood in the urine is haematuria. If you actually see blood in your urine, this is known as macroscopic haematuria.
On the other hand, if it is detected by your doctor using laboratory tests, it is known as microscopic haematuria. This is usually carried out during a medical check-up, and the blood in the urine is incidentally picked up. Macroscopic or gross haematuria is more worrying as about one in five adults are subsequently found to have bladder cancer, as opposed to microscopic haematuria, where about one in 12 had bladder cancer.

In fact, roughly 50% of those with visible blood in the urine will have an underlying cause identified. In microscopic haematuria, only about 10% will have an identifiable cause.
However, not all red-coloured urine is caused by blood. There are certain medications, such as rifampicin for tuberculosis, as well as food like beetroot, which can cause reddish urine.
Porphyria, a rare disease, can also make the urine appear dark red in colour.

What are the causes?
There are various causes of haematuria. It could be due to infection, stones, cancer, trauma, inflammation, or surgery affecting the urinary organs, which include the kidney, ureter (tube-like structure connecting the kidney and bladder), bladder and urethra (passage from the bladder to the external environment).

Besides that, certain diseases like leukaemia, as well as medications like warfarin, can cause spontaneous bleeding.In men, enlargement of the prostate (benign prostate hyperplasia) is a common cause of blood in the urine. Glomerulonephritis, a disorder affecting the kidneys, may also lead to blood appearing in the urine.

Surprisingly, strenuous exercise like long-distance running, rowing, swimming, cycling, football and boxing, have also been documented to give rise to haematuria, but this usually resolves spontaneously with rest.In other cases, despite extensive investigation, no cause can be found. This is termed idiopathic.

What needs to be done?
The doctor will first assess to ensure that not too much blood has been lost. If there is significant blood loss, a blood transfusion may be needed and further procedures to stop the bleed may be required.Otherwise, the doctor will take a full history, and this includes asking about smoking habits, exposure to industrial chemicals and any current medications.If there is burning pain around the penis or vagina when passing urine, it could be infection. Pain elsewhere in the abdomen or back could be due to stones.

Painless gross haematuria is usually a sinister sign as it could be due to a tumour.
Next would be a physical examination, which includes examination of the abdomen, the vagina for women, and rectum to assess the prostate in men. Following that, further investigations will be ordered, and this includes:

1. Urine – urine will be analysed under the microscope to confirm red blood cells, as well as to look for infection and cancer cells (urine cytology).
For microscopic haematuria to be significant, there must be persistent detection of three or more red blood cells per high-power field in two out of three urine specimens examined under the microscope. Further tests will be needed only if there is persistent significant haematuria.

2. Blood – a blood test (haemoglobin) will be done to ensure that not too much blood has been lost, as well as to confirm that there are no problems with the clotting of blood (coagulation profile and platelets level).

3. Imaging – an ultrasound, and if necessary, a computerised tomography (CT) scan or intravenous urogram (IVU) will be done to obtain images of the urinary tract/organs to look for stones, tumours or other abnormalities.

4. Flexible cystoscope – this is a soft, tube-like instrument, which has a camera at one end. It is inserted through the urethra into the bladder to enable the doctor to have a look at the bladder. It is done under local anaesthesia, where gels containing medication (lignocaine) are inserted into the urethra to numb the area.

It is a quick procedure, usually taking less than 10 minutes.
If all these tests are normal and microscopic haematuria still persists, a renal biopsy may be needed if there is also protein detected in the urine and the function of the kidney is impaired.
In this procedure, a small piece of kidney tissue is removed via a needle, guided by ultrasound or CT scan, to be examined under the microscope. This is to detect diseases of the kidney.

How is it treated?
This would depend on the cause. If there is gross blood in the urine, a catheter may be inserted into the bladder to irrigate the bladder and wash out the blood and clots. Approximately 80% of haematuria resolves by itself. If the bleeding persists, a cystoscopy may be done under anaesthesia to remove blood clots and “burn” (diathermise) the areas in the bladder that are bleeding.

If it is due to the prostate, a resection of the prostate may need to be done. Likewise, if it is tumour in the bladder, resection of the tumour needs to be done. If it is due to infection, a course of antibiotics will usually solve the problem. Medications that may affect blood-clotting need to be stopped, and if there is a medical disorder affecting the clotting of blood, this will need to be treated with blood products (like platelets and fresh frozen plasma). If it is due to a tumour or injury to the kidney, removal of the kidney (nephrectomy) or angioembolisation (occluding the blood vessel, which is bleeding, with substances such as coils) may be required. Any blood in the urine which is visible to the naked eye needs to be investigated. Persistent, significant microscopic haematuria (as defined earlier on) should be investigated as well. The main worry is an underlying cancer. A urologist is the specialist who will be the best person to consult with regarding this matter.

This article is contributed by The Star Health & Ageing Panel, which comprises a group of panellists who are not just opinion leaders in their respective fields of medical expertise, but have wide experience in medical health education for the public. The members of the panel include: Datuk Prof Dr Tan Hui Meng, consultant urologist; Dr Yap Piang Kian, consultant endocrinologist; Datuk Dr Azhari Rosman, consultant cardiologist; A/Prof Dr Philip Poi, consultant geriatrician; Dr Hew Fen Lee, consultant endocrinologist; Prof Dr Low Wah Yun, psychologist; Datuk Dr Nor Ashikin Mokhtar, consultant obstetrician and gynaecologist; Dr Lee Moon Keen, consultant neurologist; Dr Ting Hoon Chin, consultant dermatologist; Prof Khoo Ee Ming, primary care physician; Dr Ng Soo Chin, consultant haematologist. For more information, e-mailstarhealth@thestar.com.my. The Star Health & Ageing Advisory Panel provides this information for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star Health & Ageing Advisory Panel disclaims any and all liability for injury or other damages that could result from use of the information obtained from this article.