Blood in the urine

Disease Description (Causes and Symptoms)

• Definition: Hematuria is a condition in which abnormal red blood cells are mixed into the urine. It is divided into gross hematuria, which is visible to the naked eye, and microscopic hematuria, which can only be detected under a microscope.
• Pathophysiology:
  • When bleeding occurs in the urinary tract (kidneys, ureters, bladder, or urethra) or in the renal glomeruli (glomerular bleeding), red blood cells become mixed into the urine.
  • Glomerular bleeding may be accompanied by red blood cell casts (RBC casts) and significant proteinuria, as well as systemic symptoms such as edema and hypertension.
  • Nonglomerular bleeding (originating from the upper or lower urinary tract) is associated with pain, urinary symptoms, and possible clot formation due to blood coagulation.
• Main causes (including priorities):
  • Urinary tract infection (pyelonephritis, cystitis)
  • Urinary stones (kidney stones, ureteral stones)
  • Tumors (bladder cancer, renal pelvic and ureteral cancer, kidney cancer, prostate cancer)
  • Glomerular diseases (e.g., IgA nephropathy, Alport syndrome, acute glomerulonephritis)
  • Trauma (urinary tract injury)
  • Medications (anticoagulants, antiplatelet agents, some antibiotics, etc.)
  • Systemic bleeding disorders (coagulopathy, thrombocytopenia, etc.) and exercise-induced causes (after strenuous exercise)
• Main symptoms:
  • Changes in urine color (bright red, pink, or cola-colored), pain during urination (dysuria), urinary frequency, flank/back pain (stones or pyelonephritis), fever (infection), and lower-extremity edema, hypertension, and proteinuria (glomerular causes)
  • Blood clots in the urine may cause difficulty urinating (urinary retention)

Treatment Methods

• Principle: Treating the underlying cause takes priority. Depending on the cause, medication, procedures, surgery, or conservative treatment may be used.
• Medication:
  • Infection: Appropriate antibiotics (considering culture results and resistance)
  • Glomerulonephritis (immune-mediated): Steroids and immunosuppressants (depending on the type of disease); ACE inhibitors/ARBs to reduce proteinuria
  • When a coagulation abnormality is the cause of a bleeding condition: Coagulation factor replacement, platelet replacement, etc.
• Procedures/Surgery:
  • Urinary stones: Extracorporeal shock wave lithotripsy (ESWL), ureteroscopic stone removal, etc.
  • Bladder cancer: Transurethral resection of bladder tumor (TURBT); cystectomy and chemotherapy if necessary
  • Kidney tumors: Partial nephrectomy or nephrectomy
  • Urinary retention caused by bleeding in the bladder: Catheter insertion and emergency treatment
• Conservative and supportive care:
  • Fluid replacement, rest, and pain control
  • If taking anticoagulants, consult the treating physician for adjustment (consider discontinuation, dose reduction, or alternative treatment)
• Lifestyle management and precautions:
  • Avoid strenuous exercise (to prevent exercise-induced hematuria)
  • Smoking cessation is recommended because smoking increases the risk of bladder cancer
  • Be cautious with medications that may affect the kidneys, such as NSAIDs
  • Monitor urine color, urinary frequency, pain, fever, and other symptoms, and visit a medical facility immediately if they worsen
• Risk of complications:
  • Urinary retention (difficulty urinating due to blood clots), anemia, worsening infection, chronic kidney failure due to the underlying disease, or progression of cancer

Checklist Before an Outpatient Visit (Including Items to Bring and Example Questions)

• Recommended items to bring:
  • A list of all medications currently being taken (especially anticoagulants, antiplatelet agents, nonsteroidal anti-inflammatory drugs, etc.)
  • Past medical history (kidney disease, urinary tract infections, history of cancer, etc.)
  • Smoking history and whether there has been occupational exposure to carcinogens (dyes, chemicals)
  • Any recent trauma or strenuous exercise, and the start of menstruation (for women)
  • Previous test results (recent urinalysis, blood tests, kidney ultrasound/CT, etc.)
  • Photographs of the urine, if possible; records of the urine color, when the bleeding began, whether it has persisted, and related symptoms (pain, fever, etc.)
• Examples of symptom records to present to the doctor:
  • When did the hematuria begin? Is it persistent or intermittent?
  • Are blood clots visible in the urine? Are pain, fever, or urinary abnormalities present?
  • Have there been any recently started medications, procedures, trauma, or strenuous exercise?
• Useful information before testing:
  • Recent urine culture results, if available, and recent imaging results (CT, ultrasound)

Examples of General Questions to Ask the Doctor

• "What is the most likely cause of this hematuria?"
• "What additional tests, such as a urine culture, CT, or cystoscopy, are needed?"
• "What are the side effects of the prescribed medication, and what precautions should I take while taking it?"
• "Should I stop taking the anticoagulant I am currently taking? What are the risks?"
• "What is the prognosis, and when can it be considered normal again?"

Examples of Disease-Specific Questions

• "I am a smoker and have gross hematuria. Is testing for bladder cancer (or urinary tract cancer) definitely necessary? What tests should I undergo and when?"
• "I only have microscopic hematuria, with no pain or fever. Is it okay to simply observe it? At what intervals should I have regular follow-up tests (urinalysis and ultrasound)?"

(Note: Tests and treatment vary depending on the individual’s condition. In cases of acute heavy bleeding, urinary retention, severe pain, hemodynamic instability, or high fever, seek emergency medical care immediately.)